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V^otlinager  s  Encyclopedia  of  'Practical  Medicine 


Typhoid  Fever 


AND 


Typhus  Fever 


DR.  H.  CURSCHMANN 

Professor  of  Medicine,  Leipzig 


EDITED,  WITH  ADDITIONS 


WILLIAM   OSLER,  M,D, 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins 
University,  Baltimore,  Md. 


AUTHORIZED  TRANSLATION  FROM  THE  GERMAN,  UNDER  THE 
EDITORIAL  SUPERVISION  OF 

ALFRED  STENGEL,  M.D. 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania 


PHILADELPHIA  AND  LONDON 

W.   B.    SAUNDERS    &    COMPANY 
1902 


Copyright,  1901, 
By  W.  B.  SAUNDERS  &  COMPANY. 


Registered  at  Stationers'  Hall,  London,  England. 


ELECTROTYPED  BY 
WESTCOTT  Sl  THOMSON.    PHIUAOA. 


PREFACE. 


The  excellence  of  the  series  of  monographs  issued  under  the  editor- 
ship of  Professor  Nothnagel  has  been  recognized  by  all  who  are  suffi- 
ciently familiar  with  German  to  read  these  works,  and  the  series  has 
found  a  not  inconsiderable  proportion  of  its  distribution  in  this  and 
other  English-speaking  countries.  I  have  so  often  heard  regret  expressed 
by  those  whose  lack  of  familiarity  with  German  kept  these  works  beyond 
their  reach,  that  I  Avas  glad  of  the  opportunity  to  assist  in  the  bringing 
out  of  an  English  edition.  It  was  especially  gratifying  to  find  that  the 
prominent  specialists  who  were  invited  to  co-operate  by  editing  separate 
volumes  were  as  interested  as  myself  in  the  matter  of  publication  of  an. 
English  edition.  These  editors  have  been  requested  to  make  such  addi- 
tions to  the  original  articles  as  seem  necessary  to  them  to  bring  the 
articles  fully  up  to  date  and  at  the  same  time  to  adapt  them  thoroughly 
to  the  American  or  English  reader.  The  names  of  the  editors  alone 
suffice  to  assure  the  profession  that  in  the  additions  there  "will  be  pre- 
served the  same  high  standard  of  excellence  that  has  been  so  conspicuous 
a  feature  in  the  original  German  articles. 

In  all  cases  the  German  author  has  been  consulted  with  regard  to  the 
publication  of  this  edition  of  his  work,  and  has  given  specific  consent. 
In  one  case  only  it  was  unfortunately  necessary  to  substitute  for  the 
translation  of  the  German  article  an  entirely  new  one  by  an  American 
author,  on  account  of  a  previous  arrangement  of  the  German  author  to 
issue  a  translation  of  his  article  separately  from  this  series.  With  this 
exception  the  Nothnagel  series  will  be  presented  intact. 

ALFRED  STENGEL. 

7 


EDITOR'S  PREFACE. 


It  was  with  the  greatest  pleasure  that  I  undertook,  with  the  helj) 
of  Dr.  Cole,  a  member  of  my  staff,  the  editing  of  a  translation  of  Pro- 
fessor Curschmaun's  important  work  on  Typhus  and  Typhoid  Fevers. 

The  original  edition  is  recognized  by  all  special  students  of  typhoid 
fever  as  the  standard  authority  on  the  subject.  Professor  Curschmann 
has  had  exceptional  opportunities  to  study  the  diseases  considered  in 
this  monograph,  which  displays  everywhere  the  thoroughness  and  ful- 
ness which  we  all  recognize  as  characteristic  of  the  literary  work  of  the 
directors  of  the  great  medical  clinics  in  Germany.  \ 

With  the  consent  of  Professor  Curschmann,  the  additions  have  been 
made  so  as  to  run  smoothly  with  the  original  text.  The  following  are 
some  of  the  more  important  changes,  necessitated  chiefly  by  the  new 
work  done  since  the  issue  of  the  German  edition  : 

The  chapter  on  the  Bacteriology  of  Typhoid  Fever  has  been  thor- 
oughly reviewed  and  new  material  added,  particularly  on  the  distribu- 
tion of  the  typhoid  bacilli,  especially  in  the  urine,  in  the  rose-spots,  and 
in  the  blood. 

In  the  chapter  on  pathology  many  minor  additions  have  been  made, 
and  the  important  work  of  Mallory  has  been  incorporated.  The  litera- 
ture on  the  localized  lesions  due  to  the  bacillus,  particularly  of  the 
bones,  meninges,  heart,  pleura,  bladder,  etc.,  has  been  carefully  revised 
and  brought  up  to  date.  Thayer's  exhaustive  study  of  the  state  of  the 
blood  has  been  utilized.  The  surgical  complications  of  the  disease  have 
been  very  fully  revised  with  the  aid  of  Keen's  monograph. 

The  chapter  on  Perforation  and  Peritonitis  has  been  practically 
rewritten,  as  has  also  the  section  on  the  Hepatic  Complications  of 
Typhoid  Fever.  s 

Many  important  additions  have  been  made  to  the  section  on  Diag- 
nosis by  Bacteriologic  Methods,  particularly  with  reference  to  the  recent 
work  on  blood-cultures  and  on  the  detection  of  the  bacilli  in  the  urine. 

In  the  chapter  on  Treatment  I  found  little  to  change.     The  author's 


]()  EDITORS  PREFACE. 

methods  in  the  a})i>licati(Mi  ol'  hydnttlu'ru})}'  cliifer  somewhat  from  those 
in  nse  in  this  rountrv,  antl  tlu'  antipvrotio  drugs  are  not  much  in  use 
here.     AVright's  method  of  antityphoid  vaccination  has  beien  added. 

I  wislr  to  express  again  my  indebtedness  to  Dr.  Cole,  whose  work 
has  made  him  perfectly  familiar  with  all  the  recent  studies  on  the  sub- 
ject, and  who  has,  moreover,  utilized  in  the  revision  the  articles  in 
the  "Studies  in  Typhoid  Fever"  from  the  Johns  Hopkins  Hospital, 
particularly  those  of  Drs.  Flexncr,  l^'iniiey,  Thayer,  Blumer,  Parsons, 
Gushing,  Camac,  Hamburger,  and  Gwyu. 

WILLIAM  OSLER. 


CONTENTS. 


TYPHOID  FEVER. 


PAG  E 


Etiology 17 

Historical 17 

Morphology  and  Biology  of  the  Typhoid-Bacillus 26 

By  what  Route  do  the  Typhoid-Bacilli  Leave  the  Body  of  the 

Patient? 32 

The  Vitality  of  the  Typhoid-Bacilli 34 

How  do  the  Typhoid-Bacilli  Gain   Access  to  the   Body  of  the 

Individual  Infected  ? 38 

The  Most  Important  Carriei'S  'and  Modes  of  Dissemination  of  the 

Virus      40 

Transmission  through  the  Air 49 

Significance  of  Earth  in  the  Etiology 51 

Infection  and  Dissemination  through  Household  Articles  ....  54 

Factors  that  Favor  Infection  and  Dissemination  of  the  Disease     .  55 

Factors  Relating  to  the  Individual 56 

External,  not  Individual,  Influences 70 

Conclusions 77 

Pathology 79 

General  Symptomatology      79 

Summary  of  the  Post-mortem  Conditions 86 

External  Appearances 86 

■     Muscles,  Bones,  and  Joints 87 

Digestive  Organs  \ 90 

Heart  and  Vascular  System 104 

The  Spleen 107 

The  Urinary  Organs 110 

The  Respiratory  Organs 113 

The  Nervous  System 118 

Analysis  of  the  Individual  Symptoms.     Complications 122 

Alterations  in  the  External  Integument 124 

11 


12  CONTESTS. 

PAGE 

Course  of  the  Fever;  Especial  Coiulitiou  of  the  Body-Tem- 
perature        133 

Changes  iu  the  Circulatory  Organs 152 

Spleen  and  Thyroid  Gland 170 

Genito-Urinary  Organs 1^*4 

Generative  Organs 194 

Digestive  Organs 199 

Respiratory  Organs 238 

Nervous  System  and  Organs  of  Special  Sense 259 

Variations  in  Symptomatology  and  Course 287 

The  Latent  Varieties 305 

Severe  and  Moderate  Cases  of  Atypical  Course  and  Symptom- 
atology      311 

Typhoid    Fever   in  which    Symptoms   referable    to    Certain 

Organs  or  Systems  Predominate 316 

Association  of  Typhoid  Fever  with  Other  Diseases    ....  321 
Variations  in  Course  Depending  upon  Constitution,  Sex,  and 

Age 329 

Recrudescences  and  Relapses 344 

Convalescence 366 

General  Course 366 

Changes  in  Individual  Organs 373 

The  Duration  of  Convalescence 380 

The  Total  Duration  of  the  Disease 380 

Fatal  Termination.     Prognosis 382 

Time  of  Death       387 

Cause  of  Death      388 

Sudden  Death 396 

Diagnosis 400 

Clinical  Investigation 401 

Special  Differential  Diagnosis 410 

Bacteriologic  Diagnosis 419 

Methods  of  Serum-Diagnosis 423 

Prophylaxis  of  the  Disease 431 

General  Measures      .'    .  431 

Regulations  of  the  Sewage-Conditions 431 

Water-Supply 432 

Food  as  a  Source  of  Infection 434 

Prophylaxis  with  Relation  to  the  Individual 434 

Treatment 440 

Observations  on  Specific  Treatment 440 

Nursing:- and  Diet 443 


CONTENTS.  13 

PAOE 

Diet  during  the  Period  of  Defervescence  and  the  Stage  of  Con- 
valescence    451 

The  So-Called  Antipyretic  Methods  of  Treatment      453 

Hydrotherapy 454 

Antipyretic  Medicaments 460 

Treatment  of  the  Disorders  of  Individual  Organs  and  Systems    .  463 

Treatment  of  Convalescence 471 


TYPHUS   FEVER. 


Historical  •    .  , 475 

Etiology 480 

Origin  and  Mode  of  Transmission  of  the  Contagium 480 

Geographic 481 

The    Nature  "and    Mode   of  Action  of  the    Typhus    Fever 

Contagium 482 

Predisposing  Conditions 489 

Personal  Conditions 489 

Season  and  Meteorologic  Conditions 497 

General  Manifestations  of  the  Disease 497 

Pathology • 500 

General  Features 500 

The  Stage  of  Incubation 500 

The  Subsequent  Course  of  the  Disease 500 

Morbid  Anatomy 507 

The  External  Findings 507 

The  Changes  in  the  Respiratory  Organs 508 

The  Circulatory  Organs 510 

The  Digestive  Organs 510 

The  Spleen 511 

The  Genito-Urinary  Organs 512 

The  Nervous  System 512 

Symptomatology 513 

The  Temperature 513 

Alterations  in  the  Circulatory  Organs 523 

The  Spleen  and  Lymph-Glands 526 

Changes  in  the  Skin 527 

The  Nervous  System  and  Organs  of  Special  Sense     ....  534 

Disturbances  of  the  Special  Senses 540 


14  CONTENTS. 

PAGE 

Changes  in  the  Respiratory  Organs 542 

Alterations  in  the  Digestive  Tract 547 

Changes  in  the  Geuito-Urinary  Organs 548 

Variations  in  the  Course  and  Manifestations  of  the  Disease  .    .    .  551 

Kehipscs  and  Recurrences 551 

Variations  in  the  Course 554 

Relations  to,  and  Coexistence  with,  Other  Diseases     ....  562 

The  EHect  of  Constitution,  Age,  and  Sex 565 

Duration  of  the  Disease  and  Period  of  Convalescence   .    .    .  569 

,    Very  Severe  and  Fatal  Cases.     Prognosis  and  Mortality  .    .  575 

Prognosis.     Mortiility 583 

Diagnosis 594 

( ieneral  Con.siderations 594 

Differential  Diagnosis  in  Initial  Stage 595 

Diagnosis  in  Stage  of  Eruption 598 

Typhus  and  Typhoid  Roseoke 599 

Other  Differential  Signs  between  Typhus  and  Typhoid      ....  600 

Prophylaxis      604 

Regulation  of  General  and  Local  Hygienic  Conditions      ....  604 

Isolation 606 

Transportation  of  Patients .  606 

Washing  of  Hospital  Clothing 607 

Disinfecting  Clothing,  etc .  608 

Disinfection  of  Sick-Roonis 609 

Disinfection  of  Furnishings 609 

Regulations  Regarding  Discharge  of  Convalescents 610 

Treatment 612 

Specific  Treatment 612 

General  Treatment,  Nursing,  and  Diet 613 

Hydrotherapy 619 

Treatment  of  Special  Conditions  and  Organic  Changes      ....  622 


Literature 629 

Index 635 


TYPHOID  FEVER. 


TYPHOID   FEVER. 


I.  ETIOLOGY. 

HISTORICAL. 

The  recognition  of  the  causative  factors  and  of  the  nature  of  typhoid 
fever  was  long  prevented  by  the  inability  clearly  to  separate  it  anatomi- 
cally and  clinically  from  other  diseases  bearing  a  superficial  resemblance 
to  it.  Although  the  name  typhus  dates  back  to  antiquity,  it  was  not 
until  within  recent  times  applied  to  a  clearly  defined  disease,  but  to  a 
group  of  acute  febrile  conditions  attended  with  stupor  and  obscuration 
of  consciousness  (rt)^oc,  breath,  vapor).  Typhoid  fever  is,  without 
doubt,  not  a  disease  that  has  developed  or  appeared  for  the  first  time 
within  the  last  few  centuries.  Certain  statements  and  descriptions  made 
even  by  early  writers — as,  for  instance,  Hippocrates — are  applicable 
scarcely  to  any  other  disease  than  typhoid  fever,  as  "VVunderlich  spe- 
cially has  shown. ^  With  the  increasmg  importance  of  anatomic  investi- 
gation, Spigelius,  Willis,  and  Morgagni  as  early  as  the  seventeenth  and 
eighteenth  centuries  made  reports  of  post-mortem  examinations  that 
undoubtedly  indicated  typhoid  fever.  Clinical  observation,  however, 
could  not  yet  be  brought  into  perfect  accord  with  the  anatomic  con- 
ditions at  this  time ;  the  clinical  and  the  pathologic  descriptions  often 
did  not  wholly  coincide.  The  discrimination  of  the  typhoid  fevers  from 
plague,  malaria,  and  a  number  of  septic  processes  was  gradually  learned  ; 
but  until  within  quite  a  recent  period  typhoid  fever  continued  to  be  con- 
founded with  typhus  fever  and  relapsing  fever.  Less  significance  should 
be  attached  to  relapsing  fever  in  this  connection,  as  it  occurs  less  com- 
monly and  is  confined  to  a  more  circumscribed  area.  Typhus  fever 
constituted,  however,  a  serious  obstacle,  especially  in  England  and 
France,  the  countries  from  which,  at  the  close  of  the  eighteenth  and  the 
beginning  of  the  nineteenth  centuries,  the  most  substantial  impulses  for 
the  development  of  our  knowledge  of  the  disease  emanated. 

In  France  at  the  beginning  of  the  nineteenth  century  the  anatomic 
lesions  of  typhoid  fever  became   gradually  more    clearly  understood ; 

^  Geschiclde  der  Medicin. 
2  17 


18  TYI'IIOID   FEVER. 

but  for  a  loug  time  the  idea  was  uot  abandoned  that  these  lesions 
belonged  as  well  to  the  disease  that  we  know  to-day  as  typhoid  fever,  as 
to  all  of  those  conditions  known  variously  as  war-typhus,  starvation- 
typhus,  camp-typhus,  and  similar  designations,  all  of  Avhieh  were 
even  at  that  time  considered  contagious.  In  England,  on  the  other 
hand,  where  typhus  fever  had  always  been  predominant,  it  could  not  for 
a  long  time  be  understood  why  post-mortem  examination  in  the  cases  in 
question  only  exceptionally  disclosed  the  lesions  described  with  such 
detail  by  the  French  physicians. 

In  France,  Prost '  had  as  early  as  1804  demonstrated  that  the  typhoid 
fevers  were  constantly  associated  -with  definite  intestinal  lesions.  His 
conclusion  was  based  upon  the  unusually  large  amount  of  anatomic 
material  furnished  by  200  autopsies.  His  views  were  materially 
enlarged  upon  by  Petit  and  Serres,^  who  called  attention  to  the  fact  that 
under  the  conditions  in  question  especially  the  lower  portions  of  the 
small  intestine  were  involved,  and  that  the  lesions  should  be  con- 
sidered specific,  probably  resulting  from  the  action  of  a  special  poison. 
Although  Bretonueau ''  fuiiJier  determined  subsequently  that  the  intes- 
tinal mucous  membrane  itself  was  not  the  seat  of  the  morbid  process 
in  question,  but  the  lymphatic  apparatus  of  the  intestine  must  be  con- 
sidered the  basis  of  the  disease  ;  and  after  him  Louis  *  established  most 
clearly  the  relation  bet^^■een  the  intestinal  lesion  and  the  general  con- 
dition ;  although,  finally,  Chomel  ^  described  the  anatomic  lesions  more 
fully  and  the  clinical  manifestations  with  special  clearness, — an  absolute 
differentiation  between  the  typhoid  diseases,  especially  between  typhoid 
and  typhus  fever,  could  not  be  made.  Under  the  influence  of  those 
great  French  clinicians  it  was  almost  universally  believed  that,  although 
typhoid  fever  Avas  invariably  associated  with  intestinal  lesions,  it  could, 
however,  be  directly  contagious,  in  the  same  way  as  small-pox  and  other 
acute  exanthemata. 

At  the  beginning  of  the  nineteenth  centur}',  at  a  time  when  the 
French  and  the  English  were  unable  to  reach  a  clear  understanding, 
in  spite  of  exact  clinical  and  anatomic  observations,  remarkably  definite 
views,  approximating  those  of  the  present  day,  had  been  expressed  in 

^  Mededne  eclairee par  Vobservation  ct  I'ouverture  des  corps,  etc.,  Paris,  1804. 

'  Traite  de  lajievre  entero-mesenterique,  Paris,  1813. 

»"De  la  dothienterite,"  Arch.  gen.  de  med.,  1826.  The  name  dothienterite 
(fi  6odt^/v,  hemorrhagic  ulcer,  furuncle)  was  proposed  by  Bretonneau,  and  it  was 
subsequently  largely  employed  by  the  French,  especiallj'  by  Trousseau. 

*  Recherches  sur  la  maladie  conntie  sous  les  noms  de  (jastroenierite,  fievre  putride, 
adynamique,  etc.,  Paris,  1829. 

'"  Lemons  de  clinique  ynedic.     Tome  i.,  Fievi'e  typhdide,  Paris,  1834. 


ETIOLOGY.  19 

Germany.  Under  the  influence  of  Hildenbrand/  who  published  his 
important  work  in  1810,  typhus  and  typhoid  fever  began  to  be  differ- 
entiated. There  were,  as  it  appears,  less  exact  anatomic  and  clinical 
data  than  intelligent  empiric  conceptions  which  pointed  in  the  right 
direction. 

It  was  not  until  the  fourth  and  fifth  decades  of  the  nineteenth  cen- 
tury that  the  differences  of  opinion  were  harmonized.  At  this  time  it 
became  possible  to  secure  general  recognition  of  the  individuality  of  the 
two  diseases,  and  thereby  to  place  the  etiology  upon  a  firm  foundation. 
To  two  American  physicians,  Gerhard  and  Pennock,^  belongs  the  credit 
for  having  finally  established  the  differentiation.  The  clearness  of  their 
differential  diagnostic  statements  is  noteworthy  for  their  time ;  as,  for 
instance,  their  ability  to  distinguish  the  roseolous  exanthem  of  each  dis- 
ease. Gerhard  and  Pennock's  communication  was  supplemented  and 
amplified  by  numerous  papers  from  German,  French,  and  English 
sources,  among  which  those  of  Staberoh^  and  Stewart*  may  be  men- 
tioned, and,  above  all,  the  opinions  expressed  by  the  gifted  Louis  in  the 
second  edition  of  his  famous  work  in  1841,  in  which  he  unconditionally 
accepts  the  new  doctrine.  The  names  of  Jenner,  Murchison,  and 
Griesinger  are  associated  with  further  great  advances  leading  up  to  the 
views  held  at  the  present  day. 

Although  it  was  difficult  for  physicians  to  renounce  the  doctrine  of 
unity,  they  adhered,  after  its  abandonment,  to  the  conception  of  a  close 
relation  between  typhus  and  typhoid  fever.  These  views  have  not  been 
entirely  eliminated  from  some  modern  descriptions,  and  cannot  be  dis- 
lodged from  the  minds  of  some  clinicians.  In  Germany  the  credit  of 
having  recognized  fundamental  distinctions  between  the  two  diseases 
belongs  to  Griesinger,  and  especially  to  Liebermeister  in  his  classic 
description  of  typhoid  fever ;  and  the  author  of  this  article  believes 
that  he  went  a  step  further,  in  the  third  edition  of  Ziemssen's  Hand- 
bueh,  in  giving  expression  outside  of  Germany  to  this  important  dis- 
tinction by  placing  spotted  fever  among  the  acute  exanthemata,  and 
urgently  demanding  the  abandonment  of  the  designation  typhus  fever 
altogether. 

Historic  Considerations  upon  the  Etiology  of  Typhoid 
F'ever. — The  discussion  of  the  etiology  of  typhoid  fever  will  be  pre- 

1  Ueber  den  ansteckenden  Typhus,  Vienna,  1810. 

'''  "  On  the  Typhus  Fever  which  occurred  at  Philadelphia  in  18B6,  showing  the 
Distinctions  between  It  and  Dothienteritis, "  Amer.  Jour.  Med.  Sci.,  vols.  xix.  and  xs., 
1837. 

"*  Dublin  Jotir.  Med.  Sci.,  vol.  xiii.,  1838. 

*  Edinb.  Med.  and  Surg.  Jour.,  Oct.,  1840. 


20  TYPHOID  FEVER. 

cedetl  by  some  lii.storic  coiisitlcratious.  These  Avill  deiil  with  oue  of  the 
most  interesting  chapters  in  the  history  of  the  iuiectious  diseases,  and 
naturally  \\ill  rotioct  all  of  the  doubts  and  uncertainties  that  were 
encountered  iu  the  devcl<)i)mcnt  of  the  knowledge  of  the  nature  of 
tlie  disease  and  its  differentiation  from  conditions  superlicially  resem- 
bling it. 

It  neal  scarcely  be  emphasized  that  in  the  earliest  times,  before  the 
clinical  picture  of  typhoid  fever  had  assumed  definite  shape,  the  most 
varied  and  vague  factors  were  looked  upon  as  etiologic.  Especially 
apparent  from  the  descriptions  is  the  influence  resulting  from  con- 
founding other  diseiises  with  typhoid  fever.  "With  the  formation  of  a 
better  clinical  conception  of  typhoid  fever  more  definite  etiologic  views 
also  arose,  and  these  resulted  in  the  doctrme  of  putrefaction  and  decom- 
position, which  ap})earcd  next  and  lasted  for  a  long  time.  At  first, 
rather  general  and  not  specific  processes  "svere  had  in  mind  :  putrid 
decomposition  in  the  earth  and  contamination  of  the  air,  which  were 
believed  to  be  especially  effective  in  small  dwellings,  lodging-houses, 
and  other  jxjorly  ventilated  apartments,  and  occasionally  also  decomposi- 
tion of  articles  of  food  and  drink.  To  all  of  these  the  indefinite  con- 
ceptions of  cold,  overexertion,  and  emotional  disturbances  were  added  as 
of  especial  importance,  and  at  times  as  even  alone  sufficient.  With  such 
factors  in  varying  combination  etiologic  theories  were  formed.  The 
names  febris  2)utrida,  putrida  nervosa,  fievre  ataxique,  etc.  (Willisius, 
Wintringham,  Tissot,  Pinel),  are  the  offspring  of  a  period  whose  influ- 
ence was  appreciable  until  wathin  recent  times. 

The  putrefactive  theory  had  distinguished  adherents  until  beyond  the 
middle  of  the  nineteenth  century.  It  received  especial  development 
at  the  hands  of  Murchison,^  distinguished  for  his  studies  in  connection 
with  the  infectious  diseases,  who  gave  the  disease  the  name  of  pytho- 
genie  fever,  and  by  reason  of  his  great  personal  authority  and  apparently 
exact  observations  exerted  a  profound  and  lasting  influence  not  only 
upon  his  country-men,  but  also  upon  physicians  in  other  countries.  His 
views  are  reproduced  m  the  subsequent  air,  soil,  and  water  theories^ 
and  although  they  are  replaced  to-day  by  more  accurate  knowledge,  they 
led  at  the  time  to  the  adoption  in  England  of  extensive  practical  meas- 
ures, which  may  be  considered  as  constituting  the  foundation  of  a  large 
part  of  modem  hygiene. 

Murchison  considered  as  especially  dangerous  the  decomposition  of 
organic  substances,  and  particularly  that  of  human  fecal  matter.     These 

'  See  his  well-known  work,  A  Treniise  on  ihe  Continued  Fevers  of  Great  Britain, 
London,  1862.     German  edition  by  Ziilzer,  Braunschweig,  1867. 


ETIOLOGY.  21 

he  believed  to  be  of  tlieniselves  capable  of  giving  origin,  independently 
of  the  patient  and  outside  of  his  body,  to  the  (naturally  cheinic) 
poisonous  substances  generating  tyi)lioid  fever.  In  his  large  work 
and  in  many  individual  publications  Murchison  was  able  to  fortify  his 
teachings  with  numerous  illustrations  of  endemics  and  isolated  cases. 
At  times  the  drinking-water  or  an  article  of  food,  at  other  times  the  air 
of  dwelling-rooms  and  sleeping-rooms,  was  contaminated  witli  putrid 
substances  resulting  from  the  decomposition  of  human  fecal  matter,  and 
thus  became  the  immediate  cause  for  the  development  of  the  disease.. 
His  associates  and  successors  followed  the  same  line  of  thought,  without 
the  addition  of  anything  new,  so  that  their  etiologic  investigations  and 
reports  were  quite  uniform  and  even  schematic.  An  advance  appeared 
to  be  made  with  the  experimental  investigations  of  Stich,  and  subse- 
quently of  Pauum,  which  aroused  great  interest.  These  observers 
believed  themselves  able  to  induce  typhoid  fever  by  the  introduction  of 
putrid  substances  into  the  bodies  of  animals,  and  thus  to  have  estab- 
lished the  entire  subject  upon  a  firm  foundation.  It  will  be  seen  later 
that  their  conclusions  were  based  upon  a  fallacy. 

Even  before  the  time  of  Murchison,  under  the  influence,  it  is  true, 
of  the  imperfect  diiferentiation  of  typhus  and  typhoid  fever,  a  view 
wholly  opposed  to  the  decomposition-theory  had  arisen,  namely,  that  of 
direct  contagion.  It  was  especially  the  great  French  clinicians,  Leuret,' 
Bretonneau,  and  Gendrou,^  who  maintained  with  great  positiveness  that 
typhoid  fever  was  capable  of  immediate  transmission  through  the  sur- 
rounding air  from  the  sick  to  predisposed  individuals,  and  that  this  was 
by  far  the  most  common  mode  of  origin.  Trousseau  subsequently 
also  warmly  defended  this  view,  and  undertook  to  support  it  with  striking 
illustrations. 

Thus  two  views  prevailed  contemporaneously  for  a  time,  the  decom- 
position-theory and  that  of  direct  transmission,  and  frequently  coming 
in  direct  antagonism  with  each  other.  Gradually  an  intermediate  position 
was  reached  and  held  for  a  long  time,  which,  while  admitting  the  direct 
transmissibility  of  typhoid  fever,  at  the  same  time  accepted  either  as 
predominant  or  equal  in  importance  or  as  subordinate  the  spontaneous 
"miasmatic"  mode  of  development.  Each  of  these  two  theories  no 
doubt  contained  some  objective  truth.  To  Murchison  and  his  disciples 
belongs  the  great  credit  of  havmg  called  attention  especially  to  the 
danger  from  the  fecal  discharges  of  the  patient,  although  perhaps  not  in 
the  sense  of  to-day ;  while  those  who  believed  in  the  contagiousness  of 

*  "Mem.  sur  la  dothienterite  a  Nancy,"  Arch.  gen.  de  mid.,  Ser.  I.,  xviii. 

^  "  Dothienterites  observees  aux  environs  de  Chateau  du  Loir,"  Ibid.,  Ser.  I.,  xs. 


22  TV ri  10 ID  FEVER. 

the  dit^easo,  wlik-h  sub.sequently  likewise  proved  justifiable,  placed  the 
persoual  iiiHueuce  of  the  patieut,  the  view  that  the  poisou  emanated  from 
him,  in  the  foreground. 

Thus  the  way  had  been  sufficiently  prepared  for  Budd/  for  whom 
was  reserveil  the  formulation  of  the  views,  in  general  correct,  still  held 
at  the  present  day.  His  conclusions,  remarkably  acute  for  his  time, 
were  as  follows  :  Typhoid  lever  cannot  develop  spontimeously ;  every 
case  originates  immediately  from  some  antecedent  case.  The  typhoid 
poison  is  generated  by  the  patient  himself;  it  adheres  especially  to  the 
stools  with  which  it  is  evacuated.  It  thus  develops  not  outside,  as  Mur- 
chison  and  his  disciples  believed,  but  within  the  body  of  the  typhoid 
patient ;  and  it  is  not  the  product  of  indifferent  general  decomposition 
of  fecal  matter,  but  an  agent  of  specific  origin  and  specific  activity.  Budd 
even  went  so  far  as  to  consider  the  intestine  as  the  immediate  place 
of  origin  of  the  poison,  in  the  same  "way  as  the  skin  performs  a  similar 
function  with  relation  to  the  pustule  of  variola.  Also  the  conception  of 
the  transmissibility  and  the  capability  of  further  development  of  the 
poison  is  contained  in  his  distinctly  enunciated  view  that  a  minimal 
amount  thereof  is  sufficient  for  the  conveyance  of  the  disease  and  its 
further  extension.  With  logical  acumen  Budd  reached  the  fundamental 
conclusion  that  it  Avould  undoubtedly  be  possible  to  prevent  the  spread 
of  the  disease  if  methods  could  be  devised  capable  of  rendering  the 
infectious  stools  innocuous ;  it  might  even  be  hoped  that  as  a  result  of 
a  rigid  application  of  such  measures  in  every  individual  case  the  disease 
could  be  wholly  eradicated. 

Budd's  observation  for  all  tune  must  be  considered  as  masterly.  He 
is  undoubtedly  the  founder  of  the  prevailing  views  upon  the  etiology  of 
typhoid  fever.  Nevertheless,  the  path  by  which  our  present  conceptions 
have  been  reached  followed  a  long  and  intricate  course,  in  consequence 
of  the  misleading  and  obstructive  influence  of  earlier  theories. 

Although  the  pythogenic  theoiy  of  Murchison  was  gradually  dis- 
placed by  that  of  the  specificity  of  the  poison,  the  questions  as  to  the 
mode  of  dissemination  of  the  latter,  the  development  of  the  typhoid 
fever  in  individual  cases,  in  endemics  and  epidemics,  the  important 
questions  further  as  to  the  influence  of  climate,  of  season,  and  of  locality, 
interposed  great  difficulty  to  the  progress  of  knowledge.  Too  frequently 
previous  association  of  the  patient  Avith  other  cases  of  typhoid  fever  or 
their  discharges  could  not  be  demonstrated.     The  probability. or  possi- 

1  "On  Intestinal  Fever:  Its  Mode  of  Propagation,"  Lancef,  1850.  "Intestinal 
Fever  Essentially  Contagious;  Its  Mode  of  Propagation,"  etc.,  Ibid.,  1859.  "On 
Intestinal  Fever,"  Ibid.,  18G0. 


ETIOLOGY.  23 

bility  of  contaraiuation  of  articles  of  food,  of  drinking-water,  and  other 
substances  with  the  poison  appeared  likewise  not  always  adequate. 

Instead  of  more  carefully  analyzing  these  conditions,  they  were 
minimized  or  wholly  ignored,  obviously  to  the  great  disadvantage  of  the 
subject.  Study  was  directed  rather  toward  more  general  conditions, 
toward  circumstances  amid  which  the  poison  generated  by  the  patient 
and  discharged  from  him  could  be  further  developed  independently 
and  retain  its  activity,  in  order  subsequently  to  gain  entrance  under 
favorable  conditions  into  the  human  body.  In  this  way  especially  the 
earth  came  to  be  suspected  as  the  repository  and  the  place  of  generation 
of  the  poison  of  typhoid  fever.  .The  thought  that  the  poison  here 
underwent  propagation,  maturation,  and  multiplication  was  nourished 
until  finally  the  idea  was  evolved  that  such  an  intermediate  stage  of  the 
poison  was  the  rule,  and  possibly  indispensable,  in  the  dissemination  of 
typhoid  fever. 

Support  for  these  views  was  thought  to  be  found  on  retrospective 
observation  in  the  endemic  mode  of  dissemination  of  typhoid  fever,  its 
persistence  in  certain  localities  and  circumscribed  areas,  and  also  in  the 
apparently  distinctive  observation  that  in  regions  in  which  the  disease 
prevailed  the  first  cases  appeared  often  where  extensive  excavations  of 
earth  were  being  made.  This  localization-theory  has  not  been  wholly 
abandoned  even  at  the  present  day.  In  one  or  another  form  it  still 
materially  influences  etiologic  conceptions.  This  theory  of  localization 
attained  its  highest  degree  of  development  in  the  famous  doctrine  of 
Buhl  and  of  Pettenkofer,  of  the  relation  between  the  ground-water  and 
the  development  of  typhoid  fever.  BuhP  claimed  to  have  made  the 
observation  that  the  mortality  from  typhoid  fever  in  Munich  regularly 
exhibited  fluctuations  corresponding  with  the  varying  level  of  the  ground- 
water, so  that  when  •  this  level  was  high  the  mortality  was  remarkably 
low,  and  vice  versa.  Pettenkofer,^  upon  the  basis  of  elaborate  statistical 
data  and  extensive  local  observations,  further  developed  the  theory  of 
Buhl,  so  that  at  the  end  of  the  sixth  and  in  the  seventh  decade  of  the 
nineteenth  century  the  ground-water  theory  was  considered  in  Germany, 
and  probably  also  in  other  countries,  as  fully  established  for  Munich, 
and,  by  reason  of  the  adaptiveness  of  the  statistical  data,  as  applicable 
also  to  other  localities  and  cities.     Where  this  was  not  completely  so,  it 


^  "Ein  Beitrag  zur  Aetiologie  des  Typhus  in  Munchen,"  Zeitschr.  f.  Biologic,  Bd. 
i.,  1865. 

'  "Ue'ber  die  Schwankungen  der  Typhussterblichkeit  in  Munchen  von  1850  bis 
1867,"  Zeitschr.  f.  Biologic,  Bd.  v.,  1868.  "Ueber  die  Aetiologie  des  Typhus," 
Vorirdge  gehalten  in  der  Sitzung  des  artzl.  Vereins  in  Miinchen.,  1872. 


24  TYPHOID  FEVER. 

was  tliouu'lit  that  at  least  an  iucrease  in  the  inoi'tality  iVoiii  typhoid 
fever  oouUl  be  demonstrated  in  association  with   unusual   dryness. 

Althono-h  the  suj)porters  of  the  ground-water  theory  were  unable  to 
form  any  definite  conception  of  the  nature  of  the  typhoid  poison,  and 
even  permitted  interest  in  this  to  lapse  further  in  the  background  the 
more  they  became  involved  in  the  grouud-water  theorv,  thev  adhered  to 
two  views  still  valid  at  the  i)resent  day,  namely,  the  specificity  of  the 
poison  and  its  capability  of  germination  and  multiplication.  Truth  and 
error  were,  however,  mixed  in  the  further  belief  that  the  poison  after 
passing  through  a  necessary  "  process  of  maturation  "  in  the  ejirth  passed 
from  this  into  the  human  body,  being  most  frequently  transmitted  through 
the  air,  rarely  through  water  or  through  other  media.  The  escape  of 
the  poison  from  the  earth,  its  ''  exhalation,"  ^vas  believed  to  be  rendered 
difficult  in  damp  ^veather  and  with  a  high  level  of  the  ground-water,  for 
the  reason  that  its  breedmg-point  would  be  covered  by  this  water,  and 
thus  be  cut  off  from  the  surface  of  the  earth ;  while  when  the  level  of 
the  ground-water  was  low  the  deleterious  layer  of  earth  would  be  in 
direct  communication  with  the  atmospheric  air  through  the  ground-air, 
and  there  would  thus  be  no  obstruction  to  the  emanation  of  the  poison. 

Apart  from  the  fact  that  the  theory  of  Pettenkofer  ignored  the 
nature  of  the  typhoid  poison  and  retarded  its  study,  it  was  further 
attended  with  the  not  inconsiderable  disadvantage  that  it  brought 
strongly  into  the  foreground,  although  as  it  now  appears  without  suffi- 
cient ground,  the  dissemination  of  the  poison  through  the  ground-air 
and  thence  through  the  atmospheric  air,  and  as  a  result  greatly  checked 
for  a  time  the  study  of  other  etiologic  possibilities. 

It  is  especially  interesting  to  consider  the  effective  objections  of  Lieber- 
meister '  and  subsequently  of  Biermer  ^  to  the  ground-water  theory  and  dis- 
semination through  the  air,  and  to  note  their  discriminating  support  of 
another  mode  of  dissemination,  namely,  that  through  water-infection.  Their 
views  also  gained  numerous  adherents.  The  ground-water  theory,  however, 
remained  for  a  time  so  firm  that  in  not  a  few  places  epidemiologic  investi- 
gations were  adapted  to  it,  instead,  conversely,  of  deducing  etiologic  views 
from  the  facts.  As  late  as  the  years  1886  and  1887  the  author  of  this 
article  had  such  an  unfortunate  experience.''  When  he  endeavored  to  trace 
the  epidemic  occurrence  of  typhoi<l  fever  in  Hamburg  at  that  time — more  than 
10,000  persons  had  been  attacked — to  specific  infection  of  the  water  obtained 
from  the  river  El])e,  and  used  for  drinking  and  domestic  purposes,  it  was 
found  that  certain  circles  did  not  consider  it  worth  while  to  take  this  pos- 
sibility into  consideration.     The  ground-water  theory  was   believed  to   be 

'  G esammte  Ahh(indhm<jcn. 

*  Volkinanti' s  Saminl.  kiln.   Vortr.,  ISTo,  No.  .53. 

*  Curschmann,  "  Stalistisches  unci  Klinisches  iiher  den  Unterleibstyphus  in  Ham' 
burg,"  Deutsche  med.  Wochen.ickrift,  1888. 


ETIOLOGY.  25 

wholly  sufficient  to  explain  the  epidemic  and  to  overcome  the  objections 
raised  against  the  water  of  the  Elbe. 

As  has  been  seen,  one  of  the  most  valuable  aspects  of  the  doctrines 
of  Buhl  and  Pettenkofer  is  the  emphasis  placed  upon  the  vitality  and 
the  power  of  multiplication  of  the  typhoid  poison,  to  which  Budd  and 
his  pupils  had  previously  directed  attention.  We  may  recognize  in  this 
the  forerunner  of  the  present  view  of  a  living  contagiura.  As  early  as 
the  year  1871  this  view  began  to  assume  more  definite  shape.  Refer- 
ence need  be  made  only  to  the  works  of  von  Recklinghausen/  who 
called  attention  to  the  frequent  occurrence  of  cocci  in  the  organs  of 
typhoid  patients,  especially  in  the  kidneys,  as  well  as  to  the  less  success- 
ful attempts  of  Klein, ^  SokolofF,^  Fischel,*  and  others  to  demonstrate 
an  organized  typhoid  poison. 

It  was  reserved  for  Eberth,^  in  the  year  1880,  to  discover  the  bacil- 
lus at  the  present  day  definitely  recognized  as  the  cause  of  typhoid  fever, 
and  in  the  absence  of  confirmation  by  cultivation  and  inoculation,  to  estab- 
lish its  specificity  with  great  probability.  Almost  identical  observations 
were  subsequently  made  by  Robert  Koch  ^  and  Wilhelm  Meyer,'^  who 
worked  under  the  incentive  and  direction  of  Friedliinder,  while  the 
micro-organisms  described  by  Klebs  ^  are  not  at  the  present  day  considered 
identical  by  the  majority  of  bacteriologists  with  those  of  Eberth.  In 
England,  Coates  and  Crooke  confirmed  the  observations  of  Eberth,  and 
also  in  other  countries  observers  were  soon  industriously  engaged  in 
studying  the  new  bacillus,  without,  however,  materially  adding  anything 
to  the  knowledge  of  its  biology.  Neither  Coze  and  Feltz  nor  Maragliano 
succeeded  in  cultivating  and  isolating  the  pathogenic  germ. 

GafFky^  was  the  first,  as  the  result  of  a  brilliant  investigation,  to 
bring  the  entire  subject  to  its  present  firm  foundation.  He  perfected  in 
material  points  the  morphology  of  the  bacillus,  and  by  means  of  nu- 
merous painstaking  post-mortem  examinations  demonstrated  its  distribu- 
tion and  arrangement  in  the  organs  and  tissues,  and  finally  described 
the  method  for  isolating  it  and  growing  it  in  pure  culture.  Although 
GafFky  was  not  successful  in  experimentally  producing  typhoid  fever  in 

^  Wurzb.  Zeit.^  1871.  Compare  also  Eberth,  Zur  Kenniniss  der  baldei-iologischen 
Mykosen,  Leipzig,  1872. 

^  Reports  of  the  Medical  Office  of  the  Privy  Coiincil  and  Local  Government  Board^ 
No.  6,  1875. 

^  Virchow^s  Archiv,  Bd.  Ixvi.,  187G.  ^  Prager  med.  Wochenschynfi,  1878. 

^  Virchow's  Archiv,  Bd.  Ixxxi.  u.  Ixxxiii. 

^  Mittheilmigen  aus  don  kais.  Gesundheitsamte^  Bd.  i. 

'  Inaugural  Dissertation,  Berlin,  1881. 

*  Archiv.  f.  exper.  Pathol,  u.  Pharmak.,  Bd.  xii.  u.  xiii. 

"  Mittheilungen  aiis  dem  kais.  Gesund.heitsamte,  Bd.  ii. 


26  TYPHOID   FEVER. 

animals  with  these  pure  cultures,  he  was  al)U',  from  tlie  certainty  and  the 
extent  of"  his  other  observations,  especially  from  the  un(loui)ted  constancy 
of  its  occurrence  in  cases  of  typhoid  fever  and  its  absence  from  healthy 
individuals,  to  fornudate  the  detinite  conclusion  that  the  organism  is  the 
specific  cause  of  typhoid  fever. 

The  studies  of  Gaff  ky  were  followed  in  all  countries  by  an  enormous 
amount  of  work  with  the  typhoid-bacilli,  so  that  LiVscncr  a  few  years 
ago  was  able  to  make  a  collection  of  689  papers  on  this  subject.  These 
confirm  in  general  and  amplify  in  some  details  the  results  obtained  by 
Gaffky,  at  times  proceeding  skeptically,  but  still  more  frequently  going 
beyond  his  views.  At  any  rate,  at  the  present  day  a  clear  concep- 
tion has  been  formed  of  the  morphology  and  the  development  of  the 
bacillus,  and  considerable  is  known  with  regard  to  its  behavior  both 
within  and  outside  of  the  body  of  the  typhoid  patient.  Numerous 
strides  have  been  made  with  regard  to  the  presence  and  the  behavior  of 
the  bacillus,  not  alone  in  the  dead,  but  also  in  the  living  body.  The 
organism  has  been  obtained  from  the  blood,  the  spleen,  the  skin,  and 
the  dejections,  especially  the  feces  and  the  urine.  One  result  alone, 
which,  as  has  been  mentioned,  Gaffky  failed  to  secure,  has  not  yet  been 
attained,  namely,  the  development  of  the  disease  exjjerimentally  in 
animals.  Neither  by  means  of  the  earlier  crude  methods  of  feeding 
typhoid  stools  to  various  experimental  animals,  as  practised  by  Murchi- 
son,  Klein,  Klebs,  Birch-Hirschfeld,  and  others,  nor  by  inoculations 
with  pure  cultures,  has  success  as  yet  been  obtained  in  developing  true 
typhoid  fever  in  animals. 

MORPHOLOGY  AND  BIOLOGY  OF  THE  TYPHOID- 
BACILLUS. 

The  bacilli  of  Eberth,  in  their  ordinary  form,  are  comparatively 
short,  thick  rods,  with  rounded  extremities,  about  thrice  as  long  as  they 
are  wide,  and  in  absolute  length  one-third  the  diameter  of  a  red  blood- 
corpuscle.  In  ulcerated  Peyer's  patches  and  in  other  parts  at  the  height 
of  the  specific  lesions  the  bacilli  form,  by  longitudinal  application  to  one 
another,  filamentous  structures,  first  described  by  Gaffky  as  "  pseudo- 
filaments."  Under  various  circumstances  the  bacilli  undergo  changes  in 
form,  size,  and  arrangement.  Thus  the  pseudo-filaments  already 
mentioned  will  be  found  in  old  bouillon-cultures  or  gelatin-cultures, 
as  w^ell  as  on  ])otato  of  acid  reaction,  growing  to  remarkably  long 
structures.  The  individual  bacilli  also  appear  to  become  plumper  upon 
gelatin  and  potato  than   upon  agar  or  bouillon.      They  yield  up  these 


ETIOLOGY. 


27 


peculiarities,    however,  when    transferred    to    other  nutrient  media,  in 
accordance  with  the  character  of  the  latter. 

Spore-formation  was  formerly  incorrectly  believed  to  take  place  in 
the  bacilli,  and  the  bright  bodies  that  failed  to  take  the  stain  lying  at 


Fig.  1.— Typhoid-bacilli ;  impress-preparation. 


the  extremities  as  well  as  in  the  middle  of  the  bacilli  were  thought 
to  be  spores.  ■  These  are  at  the  present  time  considered  as  deficiencies, 
attributable  either  to  a  process  of  involution  m  the  bacilli  or  as  an 
artefact  developed  in  heating  and   staining  (H,  Buchner '). 


Fig.    2.— Typhoid-bacilli ;   pure   culture 
with  pseudo-filaments. 


Fig.  3.— Typhoid-bacilli  with  flagella; 
stained  by  Loffler's  method. 


When  cultivated  in  suitable  fluid  media  (bouillon)  and  observed  in 
hanging-drop,  the  bacilli  exhibit  active  spontaneous  movement,  in  which 
both  the  individual  rods  as  well  as  the  pseudo-filaments  participate. 
This  is  dependent,  as  Loffler  has  demonstrated  by  special  methods  of 

'  CentralblaUf.  Bakteriologie  u.  Parasltoikundc,  Bd.  iv. 


28  TYPHOID  FEVER. 

staiuing,  upon  the  preseucc  of  flagclla,  ^\"llich  arise  iu  large  uumbers,  up 
to  15  and  even  20  and  more,  from  all  parts  of  the  surface  of  the  bacilli, 
and  iu  suitable  preparations  can  frequently  be  found  detached  and  lying 
free.  So  far  a;?  is  known,  among  bodies  resembling  the  tyj)hoid-bacillus, 
spontaneous  movement,  together  witii  tlagella  causing  it,  occurs  oidy  in 
Bacillus  coli  and  closely  related  forms.  A  diiference  appears,  however, 
to  reside  ui  the  fact  that  the  number  of  flagclla  attached  to  Bacillus 
coli  is  much  smaller,  being  stated  to  be  never  more  than   10. 

Typhoid-bacilli  can  be  stained  with  anilin  dyes,  but  with  more 
difficulty  than  many  other  pathogenic  micro-organisms.  Jt  is  charac- 
teristic that  staining  by  the  method  of  Gram  is  never  successful.  At 
times,  especially  in  old  cultures  u})ou  feebly  acid  potato,  the  bacteria 
exhibit  strongly  refractive  polar  bodies,  which  stain  more  readily  and 
more  deeply  than  the  remauider  of  the  body  of  the  bacteria  (H.  Buch- 
ner  ^).  These  also  are  undoubtedly  not  to  be  considered  as  spores,  as  is 
indicated  by  the  fact  that  the  organisms  in  which  they  are  contained  do 
not  exhibit  increased  po^vers  of  resistance.  Probably  the  appearance 
of  the  polar  bodies  likewise  is  rather  to  be  referred  to  an  involutional 
process. 

Even  though,  as  is  unanimously  agreed  by  the  most  experienced 
observers,  the  severity  of  an  attack  of  typhoid  fever  is  by  no  means 
always  proportionate  to  the  nmnber  of  bacilli  in  the  organs  after  death 
and  during  life,  and  as  a  matter  of  fact  remarkably  few  bacilli  are 
occasionally  found  iu  se\'ere  cases,  it  is  generally  easy,  with  a  little  skill, 
to  obtain  the  pathogenic  bacilli  from  the  spleen,  the  mesenteric  glands, 
and  Peyer's  patches,  especially  at  the  height  of  infiltration  and  with 
beginning  ulceration.  That  they  can  be  cultivated  from  the  blood  and 
the  spleen  during  life,  tbough  with  greater  difficulty,  and  also  from  the 
dejections  and  the  excretions,  has  already  been  mentioned. 

In  all  of  these  connections  it  is  important  to  know  that  the  bacillus 
thrives  best  at  the  temperature  of  the  body,  about  37°  C,  although 
it  develops  rapidly  and  abimdantly  also  at  lower  temperatures,  as, 
for  instance,  at  ordinary  room-temperature.  Like  the  majority  of 
pathogenic  micro-organisms,  the  typhoid-bacillus  displays  facultative 
anaerobiosis — that  is,  it  lives  and  develops  either  with  exclusion  of 
oxygen  (Liborius)  or  with  access  of  oxygen — in  the  latter  event,  it  is 
true,  with  greater  energy  and  in  greater  abundance.  The  cultivation 
of  the  bacillus  can  be  effected  readily  and  upon  various  culture-media  : 
upon  gelatin,  agar,  blood-serum,  and  especially  upon  potato.  An 
abundant  growth  takes  place  even  when  the  last-named  medium  pos- 

^  Loc.  cit. 


ETIOLOGY.  29 

sesses  a  slightly  acid  reaction.  The  bacillus  exhibits  active  development 
and  multiplication  likewise  in  fluids,  especially  in  bouillon  and  milk. 
The  latter  is  rendered  feebly  acid,  without  undergoing  coagulation, 
even  after  having  been  exposed  for  a  considerable  time  to  the  action 
of  the  bacillus.  The  bouillon  is  rendered  distinctly  turbid  in  conse- 
quence of  the  development  of  the  bacilli.  A  slight  sediment  that 
develops  on  standing  separates  on  agitation  into  uniform  minute  parti- 
cles. That  the  bacilli  thrive  luxuriantly,  under  favorable  conditions, 
upon  articles  of  food  constituted  of  the  substances  named  or  of  related 
substances  need  only  be  mentioned.  We  shall  dwell  more  fully  upon 
the  importance  of  this  matter  in  considering  the  special  etiology. 

When  grown  in  a  media  containing  glucose,  lactose,  or  saccharose,  there 
is  no  production  of  gas.  When  introduced  into  the  peritoneal  cavity  of 
immunized  guinea-pigs,  or  when  introduced,  together  with  serum  from  an 
immune  animal,  into  the  peritonea!  cavity  of  normal  guinea-pigs,  the  bacilli 
quickly  lose  their  motility  and  break  up  into  small  granules — the  so-called 
Pfeiffer's  phen(jmenon  (Pfeiffer  and  Kolle  ^).  If  a  bouillon  culture  of  the 
typhoid-bacillus  is  mixed  with  serum  from  an  immune  animal  or  from  a  per- 
son after  an  attack  of  the  disease,  the  bacilli  become  immobile  and  collect 
into  groups  or  clumps  (Durham').  Finally,  if  such  a  culture  is  mixed 
with  serum  from  a  patient  during  an  attack  of  the  disease,  a  similar  reaction 
takes  place  (Widal  ■'). 

The  especial  behavior  of  cultures  of  the  bacillus  of  Eberth  upon  the  solid 
and  liquid  nutrient  media  mentioned  has  been  determined  most  minutely. 
With  reference  to  the  details,  which  would  be  out  of  place  in  a  work  of  this 
kind,  the  special  treatises  should  be  consulted.     Some  statements  may  be  made' 
here  with  reference  to  the  behavior  of  the  bacillus  on  gelatin  and  agar. 

Stab-cultures  in  gelatin  appear  as  delicate,  grayish-white,  slightly  granular 
filaments,  becoming  more  attenuated  toward  the  bottom  of  the  test-tube. 
Upon  the  surface  of  the  gelatin  the  bacillus  exhibits  active  growth  in  the 
form  of  a  thin,  bluish-gray  or  greenish-gray,  slightly  iridescent  deposit, 
proceeding  from  the  point  of  puncture  and  soon  reaching  the  border  of  the 
glass.  On  closer  inspection  it  will  be  noted  that  the  outer  border  is  not 
regular,  but  slightly  serrated.  The  bacillus  forms  a  similar  thin,  iridescent, 
grayish-white  or  bluish-white  deposit  in  gelatin  plate-cultures.  Here  the 
superficial  cultures,  which  exhibit  no  trace  of  liquefaction,  appear  at  first  as 
small,  distinct,  yellowish  or  grayish-yellow  granules.  After  a  short  time 
larger  circular  spots  appear,  similar  in  color  to  the  deposits  in  stab-culture 
and  streak-culture,  grayish  white  and  likewise  iridescent.  Soon  the  center 
of  such  a  spot  appears  grayish  yellow  and  opaque,  while  toward  the  periphery 
the  culture  gradually  becomes  thinner  and  more  translucent.  These  small 
areas  also  have  an  irregular,  serrated  margin,  which,  as  microscopic  exami- 
nation shows,  represents  a  delicate  wrinkling  of  the  culture,  extending  from 
center  to  the  periphery. 

Stab-cultures  in  agar  also  appear  as  delicate,  slightly  granular,  grayish- 
white  filaments.  Here  likewise  the  superficial  growth  about  the  point  of 
puncture  is  active,  so  that  it  soon  approaches  the  wall  of  the  test-tube,  but 

^  Zeitschr.  f.  Hygiene,  Bd.  xxi.  '^  Proc.  of  the  Royal  Soc,  Bd.  lix. 

^  Bull,  med.,  1896. 


30  TYPHOID   FEVER. 

the  margin  is  not  serrated,  but  rather  round  and  reiruhxr.  Upon  agar-plates 
also  the  hirge,  usually  round  or  oblong  colonies  are  not  serrated  at  the 
perij)hery  as  on  gelatin,  /rhey  appear  opacjue  and  yellowish  white  at  the 
center,  and  more  translucent,  whitish,  and  not  opalescent  towartl  the  perii)hery. 
Microsco})>cally  these  cultures  likewise  are  more  or  less  coarsely  punctate, 
with  centrifugal  linear  formations  similar  to  those  upon  gelatin. 

Especially  noteworthy  is  the  behavior  of  the  typhoid-bacillus  upou 
potato,  as  first  carefully  studied  by  Gafi'ky,  a  feature  that,  accoi'diug  to 
existing  knowledge,  is  not  exhibiteil  by  any  other  pathogenic  micro-organ- 
ism. If  a  disk  of  boiled  potato  of  feebly  acid  reaction  is  inoculated  with 
a  typhoid  culture,  scarcely  any  difference  in  the  appearance  of  its  surface 
will  be  appreciable  to  the  untrained  eye  after  the  lapse  of  forty-eight  hours, 
as  compared  with  the  surface  of  a  sterile  disk  of  potato  similarly  exposed  but 
not  so  inoculated.  On  more  cai'eful  scrutiny,  however,  the  infected  potato 
will  appear  somewhat  less  smooth  and  more  moist  for  a  greater  or  lesser 
distance  from  the  point  of  inoculation.  If  a  platinum  looj)  be  stroked  over 
this  area,  a  sense  of  increased  resistance  will  be  felt  as  compared  with  the 
uninoculated  potato,  and  at  times  it  is  possible  to  detach  small  filaments  or 
threads  with  the  loop.  In  a  word,  one  can  convince  himself  that,  starting 
from  the  point  of  inoculation,  an  extremely  delicate,  moist,  glistening,  color- 
less, transparent  coating  has  formed  upon  the  potato.  On  microscopic  exam- 
ination this  mend)raue  will  be  found  to  consist  of  a  pure  cultui-e  of  typhoid- 
bacilli,  which,  transferred  to  various  nutrient  media,  exhibit  their  charac- 
teristic peculiarities,  especially  the  spontaneous  movement  in  bouillon  pre- 
viously referred  to.  Since  it  was  first  described  by  Gaff  ky,  this  scarcely 
visible  deposit  has  been  recognized  by  all  oliservers  as  an  especially  impor- 
tant characteristic.  This  opinion  is  naturally  not  influenced  by  the  observa- 
tion that  u])on  potato  of  neutral  or  alkaline  reaction  or  rendered  artificially 
alkaline  the  membrane  becomes  visible  as  a  greenish-white  or  yellowish- 
gray  or  even  bluish  coating,  which  not  rarely  is  less  extensive. 

If  after  these  few  references  to  the  morphology  and  the  physiology 
of  the  Eberth  bacillus  we  pass  to  a  consideration  of  its  role  in  the 
development  and  dissemination  of  typhoid  fever,  and  to  a  description  of 
the  properties  that  confer  this  power  upon  it,  the  question  arises : 

Can  typhoid  fever  he  experimentally  induced  in  animals  by  inoculation 
of  the  typhoid-haciUusf 

The  establishment  of  the  etiology  of  typhoid  fever  has  been  in  no 
small  measure  restrained  by  the  circumstance  that  a  disease  wholly  cor- 
responding to  typhoid  fever  in  human  beings  apparently  does  not  occur 
in  any  species  of  animal.  It  was,  therefore,  from  the  outset  improb- 
able that  the  disease  could  be  developed  experimentally,  and  as  a  matter 
of  fact  this  has  not  yet  been  possible.  Gaff  ky,  in  his  well-known  work,^ 
was  unable  either  after  administration  of  pure  cultures  of  the  bacillus 
by  the  mouth  or  after  intravenous  injection  to  obtain  decisive  results ; 
and  also  the  experiments  of  Friinkel  and  Simmonds,^  however  valuable 

'  Loc.  cit. 

^Centralblnfff.  /din.  Mrd.^  No.  44,  1885;  No.  39,  1886.  Die  atiologische  Bedeu- 
tnyif)  des  T)/phiisbacillus,  Hamburg,  1886.     Zeitschr.  f.  Hygiene.,  Bd.  ii. 


ETIOLOGY.  31 

their  results  in  other  respects,  have  yielded  no  wholly  conclusive  results 
in  this  connection. 

The  investigators  named  were  able  by  intravenous  as  well  as  })y  intraperi- 
toneal injection  of  large  amounts  of  pure  cultures  of  typhoid-bacilli  to  cause 
rapidly  fatal  symptoms  in  mice,  with  peculiar  anatomic  lesions  :  swelling, 
even  isolated  ulceration  of  the  follicles  of  the  small  and  the  large  intestine, 
together  with  recent  infiltration  of  the  mesenteric  glands,  cloudy  swelling  of 
the  liver  and  the  kidneys,  and  considerable  enlargement  of  the  spleen. 
Microscopic  examination  disclosed  also  the  presence  of  large  numbers  of 
typhoid-bacilli  in  the  dead  body  and  especial  accumulation  of  them  in  the 
spleen.  Frankel  and  Simmonds,  however,  although  they  considered  their 
experiments  of  great  significance — forming  the  foundation  for  subsequent 
experiments  in  immunity  and  cure — were  cautious  enough  not  to  identify 
completely  the  symptoms  induced  with  typhoid  fever.  It  was  soon  found  ^ 
also  that  no  noteworthy  multiplication  of  the  bacilli  introduced  into  the 
animals  took  place  in  the  living  organism.  In  addition,  it  was  noted  that 
inoculation  of  small  numbers  of  typhoid-bacilli  did  not — as  in  the  case  of 
other  actively  pathogenic  micro-organisms,  as,  for  instance,  anthrax — give 
rise  to  noteworthy  symptoms.  Finally,  the  circumstance  that  the  animals 
generally  died  before  the  end  of  the  first  day  and  earlier,  but  scarcely  ever 
later  than  after  three  days,  aroused  suspicion  that  the  condition  was  rather 
a  direct  intoxication  than  a  true  infectious  disease  resulting  from  the  multi- 
plication and  continued  development  of  the  bacilli. 

The  certainty  of  the  view  that  the  condition  is  due  to  the  action  of  toxins 
and  not  of  the  bacilli  was  established  by  the  experiments  of  Sirotinin,^ 
Brieger,  Kitasato,  and  Wassermann.^  By  boiling  the  cultures  or  by  elim- 
inating the  bacteria  by  filtration  it  was  possible  to  introduce  the  toxins  alone 
into  the  animals,  and  thereby  to  obtain  the  same  results  as  Frankel  and 
Simmonds. 

The  statements  of  more  recent  observers,*  that  by  systematic  augmentation 
of  the  virulence  of  the  bacilli  they  can  be  rendered  actively  pathogenic  for 
animals — that  is,  their  further  development  in  the  living  body  with  the  pro- 
duction of  typical  symptoms  can  be  brought  about — yet  require  confirma- 
tion. In  such  an  event  material  advantage  w^ould  be  expected  less  for  the 
etiology  than  for  the  solution  of  certain  therapeutic  problems. 

In  none  of  the  previously  quoted  experiments  do  any  of  the  observers 
claim  to  have  produced  in  animals  a  disease  with  a  course  resembling  that 
seen  in  human  typhoid.  A  later  observer,  Remlinger,^  found  that  by  pro- 
longed feeding  of  rats  and  rabbits  on  vegetables  soaked  in  water  containing 
typhoid  bacilli  he  was  able  to  induce  a  continued  fever  lasting  from  ten  to 
twelve  days,  accompanied  by  diarrhea,  loss  of  appetite,  and  wasting.  Four 
of  eight  rabbits  experimented  upon  became  sick;  one  was  killed  on  the 

'See  the  articles  of  Baumgarten,  Centralblalt  f.  kiln.  Med.^  1886.  "Wolfowicz 
(Baumgarten),  Inaugural  Dissertation,  Konigsberg,  1887.  Sirotinin,  Zeitschr.  f. 
Hygiene,  Bd.  i.,  1886.  Beumer  and  Peiper,  Ibid.,  Bd.  i.  u.  ii.  K.  Stern,  Volkmann's 
Samml.  kliji.   Vortr.,  Neue  Folge,  No.  138. 

'■'  Loc.  cit.  ^  Zeitschr.  f.  Hygiene,  Bd.  xii. 

*  Gilbert  and  Girode,  Comptes  rendus  de  la  Societe  d.e  Biologie,  1891,  No.  16. 
Chantemesse  and  Widal,  A^inales  de  I'hisiiiut  Pasteur,  1892,  T.  vi.,  No.  11.  Sana- 
relli,  Ibid.,  T.  vi.  ;  Ibid.,  T.  viii. 

^  Ann.  de  V Inst.  Pasteur,  T.  xi. 


32  TYPHOID  FEVER. 

twelfth  day,  and  one  died  on  the  twelfth  day  of  fever.  Three  of  the  four 
gave  a  positive  agglutination  reaction.  Auto))sies  on  the  two  latter  rabhits 
showed  swelling  of  spleen,  lyiuph-glaiuls,  and  Peyer's  ]iatehes,  and  there 
were  a  few  ulcers  in  the  lower  part  of  the  small  howel.  Typhoid  bacilli 
were  obtained  from  the  spleen.  These  very  striking  and  unique  observations 
have  not  yet  been  coufirmed. 

Taking  uj)  now  the  special  questions  as  to  the  development  of  typhoid 
fever  in  human  beings,  one  of  the  first  and  most  inn)ortant  will  be : 
How  and  by  what  route  do  the  infectious  agents  leave  the  body  of  the 
patient?  Then  the  question  will  naturally  arise  as  to  the  further 
behavior  of  the  bacilli,  in  accordance  with  the  varying  conditions  under 
which  they  are  evacuated  and  deposited.  Especially  will  it  have  to  be 
determined  under  what  conditions  and  for  how  long  a  time  they  retain 
their  vitality  or  are  capable  of  multiplication  independently  of  the 
j)atieat. 

BY  WHAT   ROUTE    DO  THE   TYPHOID-BACILLI   LEAVE 
THE  BODY  OF  THE  PATIENT? 

In  spite  of  numerous  investigations,  we  are  still  in  the  first  stage  of 
knowledge  with  respect  to  this  question.  The  secretions  and  excretions 
of  the  patient,  as  well  as  bis  blood,  have  naturally  received  especial 
attention.  The  blood  is  scarcely  to  be  taken  into  consideration  as 
a  medium  of  infection.  Also  the  sweat,  the  expectoration,  and  the 
expired  air  appear  to  be  of  slight  significance  as  carriers  of  the 
germs  of  infection.  Direct  escape  of  the  bacilli  with  the  sweat  is  more 
than  doubtful.  Isolated  results  believed  to  be  positive  are  probably  to 
be  considered  as  due  to  accidental  contamination  of  the  skin  from  the 
intestine.  Although  typhoid-bacilli  have  been  demonstrated  in  the  dis- 
eased lung  in  some  cases  of  pneumonia,  and,  accordingly,  elimination  of 
bacilli  in  the  sputum  and  the  expired  air  cannot  be  denied,  these  media 
also  probably  act  only  exceptionally  as  carriers  of  the  infection.  The 
statement  of  Sicard^  as  to  the  almost  constant  presence  of  typhoid- 
bacilli  in  the  expired  air  of  typhoid  patients  is  most  remarkable,  and 
requires  confirmation. 

Far  more  important  than  all  of  the  sources  hitherto  considered  are 
the  fecal  discharges  and  uriue.  Generally  these  are  probal)ly  the  exclu- 
sive media  by  which  typhoid-bacilli  leave  the  body.  The  history  of 
typhoid  fever  teaches  that  even  the  older  authors,  naturally  from  different 
standpoints,  considered  the  stools  as  the  source  and  origin  of  the  disease- 
virus.     After  the  discovery  of  the  typhoid -bacilli  these  views  were  con- 

^  Sejnaine  medlcale,  1892,  No.  4.  i^xl_ 


ETIOLOGY.  33 

siderably  fortified  by  the  demonstration  of  the  constancy  and  the  abun- 
dance of  the  micro-organisms  in  the  medullary  infiltration  of  the  intes- 
tine, in  consequence  of  which  opportunity  for  admixture  with  intestinal 
contents  is  continuously  afforded  from  the  earliest  stages  of  the  disease  to 
the  period  of  exfoliation  and  the  completion  of  the  process  of  ulcera- 
tion. If,  in  addition  to  the  abundance  of  the  bacilli  in  the  portions 
of  intestine  the  seat  of  the  specific  lesions,  the  relatively  long  duration 
of  the  latter  and  the  number  and  copiousness  of  the  daily  fecal  dis- 
charges are  taken  into  consideration,  there  can  be  no  doubt  that  the 
stools  constitute  a  prolific  source  for  the  contagium  of  typhoid  fever. 
The  bacteriologic  examination  of  typhoid  stools  has  also  demonstrated 
indubitably  and  frequently  the  presence  of  living  typhoid-bacilli.^ 
Recent  observers  have  established  this  fact  with  certainty ;  as,  for 
instance,  Chantemesse,^  who  in  examination  of  the  stools  of  16  typhoid 
patients  failed  to  find  the  bacilli  only  thrice.  They  are  found  most  con- 
stantly, in  accordance  with  the  nature  of  anatomic  lesions,  from  the 
beginning  of  the  second  week  to  the  end  of  the  third  week  and  later, 
or  from  the  period  of  medullary  infiltration  of  the  lymphatic  structures, 
their  exfoliation  and  ulceration,  until  the  complete  cicatrization  of  the 
ulcers. 

On  account  of  the  difficulty  attending  examination  of  the  stools  for 
typhoid-bacilli,  a  simple  and  reliable  method  for  their  isolation  has  long  been 
wanting.  That  these  difficulties  are  dependent  especially  upon  the  constant 
presence  of  numerous  other  micro-organisms  is  obvious.  The  most  trouble- 
some of  these  is  the  colon  bacillus,  which  resembles  the  typhoid-bacillus  in  so 
many  respects.  The  efforts  to  isolate  the  typhoid-bacillus  from  the  stools, 
and  especially  to  differentiate  it  from  the  colon  bacillus,  have  resulted  in 
the  publication  of  several  hundred  papers. 

Up  to  the  time  of  the  introduction  by  Eisner  ^  of  the  medium  now 
known  by  his  name,  the  isolation  of  typhoid-bacilli  from  the  stools  presented 
almost  insurmountable  difficulties.  By  the  use  of  this  medium  Eisner,* 
Brieger,^  Richardson,®  and  others  were  able  to  isolate  the  typhoid-bacilli 
from  the  feces  of  typhoid  patients  during  the  febrile  stage  in  a  large  propor- 
tion of  cases.  In  these  cultures,  however,  the  possibility  of  contamination 
by  urine  was  not  guarded  against.  Capaldi,'  Piorkowski,®  Remy,®  and 
others,  by  the  use  of  special  media,  have  also  been  able  to  demonstrate,  with 

^  Fraiikel  and  Simmonds,  in  their  earliest  publications.  Pfeiffer,  Deutsche  med. 
Wochenschrlft,  1885,  No.  29.  Merkel  and  Goldschmidt,  Centralblatt  f.  klin.  Med., 
1887,  No.  22.  Chantemesse  and  Widal,  Gaz.  hebd.,  1887,  No.  9.  Karlinski,  Ceniral- 
blatt  f.  Bakteriologie  u.  Parasitenkunde,  Bd.  vii.  Vilchour,  Lancet,  1886,  vol.  ii., 
No.  3. 

2  Soc.  de  Biol.,  Meeting  Feb.  22,  1896.  ^  Zeit.  f.  Hyg.,  Bd.  xxi.,  1895. 

*  Loc.  cit.  -0  Deutsch.  med.   Woch.,  1895. 

^  Boston  Med.  and  Surg.  Jour.,  vol.  cxxxvii.,  No.  18. 

7  Zeii.f.  Hyg.,  Bd.  xxiii.  s  Berlin,  klin.   Woch.,  1899,  No.  7. 

^  Ann.  de  I'Inst.  Pasteur,  T.  xiv.  ;  also  T.  xv. 
3 


34  TYPHOID  FEVER. 

more  or  less  ease,  the  bacillus  of  typlioitl  in  a  large  proportion  of  cases. 
Lately,  Hiss'  Nvith  a  new  method  has  isolated  the  typhoid-bacillus  from  the 
feces  in  17  cases  out  of  21  studied.  They  occurred  only  rai-ely  before  the 
first  day  of  the  second  week,  and  dit^appcared  with  the  fall  of  the  fever. 

During  the  past  few  years  various  ol)servers  have  demonstrated  the  great 
frequency  with  which  typhoid-liacilli  occur  in  the  urine,  and  have  called 
attention  to  the  important  role  of  this  secretion  in  the  spread  of  the  disease. 
In  1890,  Neumann"^  demonstrated  typhoid-bacilli  in  the  urine  of  11  out  of 
48  cases  examined.  His  results  were  received  with  some  skepticism,  how- 
ever, and  received  no  confirmation  until  Petruschky,^  in  1898,  published  the 
results  of  cultures  made  from  the  urine  in  50  cases,  with  isolation  of  B. 
typhosus  from  8.  Later,  Richardson  *  obtained  the  bacilli  from  23  out  of 
104  cases  examined — 22.1  percent.  ;  and  Horton-Smith'' obtained  them  from 
11  of  39  cases — 28  j^er  cent. — the  urine  containing  at  times  as  many  as 
500,000,000  organisms  in  each  cubic  centimeter.  During  the  ])ast  year, 
1900-1901,  from  the  urine  of  55  tyjjhoid  fever  patients  in  the  Johns  Hop- 
kins Hospital  the  typhoid-liacilli  were  isolated  in  19  cases.  While  the  fact 
of  the  frequency  of  the  bacilli  in  the  urine  is  at  times  of  importance  in 
diagnosis,  its  greatest  importance  is  in  relation  to  the  great  danger  of  the 
spread  and  transmission  of  the  disease.  It  shows  the  extreme  care  which 
should  be  observed  in  sterilization  of  the  urine,  to  guard  against  any  chance 
contamination  of  the  water-supply  or  food. 

THE  VITALITY  OF  THE  TYPHOID-BACILLL 

What  are  the  conditions  necessary  for  preserving  the  vitality  of  the 
typhoid-bacillus  within  and  outside  the  human  body,  and  what  relation- 
ship do  these  conditions  bear  to  infection  of  the  individual  and  to  the 
general  dissemination  of  the  disease?  Are  these  conditions,  and  the 
relation  of  the  typhoid-bacillus  to  them,  sufficiently  well  understood 
that  an  explanation  of  the  recognized  methods  of  origin  and  spread  of 
typhoid  fever  is  possible?  Numerous  investigations  in  regard  to  the 
vitality  of  the  typhoid-bacillus  imder  various  conditions  have  yielded 
important  results.  In  general,  the  results  of  these  investigations  have 
made  a  positive  answer  to  the  latter  question  possible.  Even  the 
absence  of  spore  formation,  which  is  so  important  with  relation  to  the 
resistance  of  bacteria,  is  not  sufficient  to  throw  doubt  on  the  pathogenic 
significance  of  the  typhoid-bacillus. 

A  large  series  of  observations  afford  important  evidence  in  favor  of 
the  persistence  of  the  bacilli  in  the  living  human  body.  The  typhoid- 
bacillus  has  been  found  in  inflammatory  exudates  and  in  periostitic  and 
muscular  collections  of  pus  caused  by  typhoid-bacilli,  alive  and  capable 
of  multiplication  as  long  as  a  year  and  even  longer  after  an  attack  of 
the  disease  (Sahli,  Hintz).      It  is  true  that  even  should  the  bacilli  be 

»  Med.  News,  vol.  Ixxviii.,  No.  19.         ''  Berlin,  klin.   Woch.,  1890,  S.  121. 
3  Centralbl.  f.  BaL,  1898,  No.  14.  *  Jour.  Exper.  Med.,  vol.  iii.;  also  vol.  iv. 

5  Lancet,  1900,  vol.  i.. 


ETIOLOGY.  35 

thrown  oif  as  a  result  of  spontaneous  rupture  or  of  incision  of  such  foci, 
typhoid  infection  will  not,  as  a  rule,  be  caused  thereby.  Nevertheless, 
in  rare  cases  of  obscure  etiology  such  a  possibility  should  not  be  left  out 
of  consideration. 

The  resistance  of  the  Ijacilli  appears  to  be  nitlier  limited  in  the  human 
cadaver.  Although  multiplication  has  been  observed  to  take  place  shortly 
after  death  (Friinkel  and  Simmonds,'  Reher  ^),  the  occurrence  of  putre- 
faction soon  exerts  an  injurious  influence.  That  this  action  cannot 
always  be  depended  upon,  however,  and  that  from  the  prophylactic 
point  of  view  careful  consideration  must  be  given  to  the  bodies  of 
those  dead  of  typhoid  fever,  appear  demonstrated  by  the  observations 
of  Karliuski  and  of  Petri,  the  former  of  whom  found  living  bacilli  in 
human  cadavers  after  three  months,  while  the  latter  found  them  in  a 
living  state  in  the  bodies  of  dead  animals  as  late  as  the  seventeenth  day. 
The  ])ersistence  of  the  bacilli  after  they  have  left  the  human  body  is 
worthy  of  further  investigation  in  various  directions,  physical  as  well  as 
chemic. 

With  regard  to  the  influence  of  various  temperatures,  it  has  already 
been  mentioned  that  the  physiologic  body  temperature  is  most  favor- 
able to  growth  and  development ;  but  also  moderate  external  tem- 
peratures appear  to  exert  no  injurious  influence.  The  typhoid-bacilli 
are  extremely  resistant  to  even  considerable  degrees  of  cold.  They 
persist  at  temperatures  as  low  as  —  10°  C  (14°  F.),  and  even  repeated 
freezing  and  thawing  of  fluid  containing  the  bacilli  do  not  appear  to 
destroy  them  (Chantemesse  and  AVidal,  Janowsky^).  The  most 
extreme  illustration  in  this  connection  is  given  by  Prudden,*  who  observed 
that  typhoid-bacilli  kept  in  ice  at  a  temperature  between  —  1°  C.  (30.2° 
F.)  and  -  1 1  °  C.  (1 2.2 °  F.)  retained  their  vitality  for  three  months.  The 
bacilli  are  far  more  sensitive  to  high  temperatures,  cultures  dying  in 
from  ten  to  fifteen  minutes  at  a  temperature  of  60°  R.  (1()7°  F.).  Heat 
is  supplemented  by  light  in  the  destruction  of  the  bacilli,  which,  as 
Buchner^  was  the  first  to  show,  and  then  Janowsky''  and  Gail  lard,"  die 
in  direct  sunlight  in  the  course  of  a  few  hours,  while  simple  diffuse  day- 
light appears  to  influence  them  far  less  unfavorably. 

The  bacilli  are  comparatively  resistant  to  drying.  Mixed  with  indif- 
ferent  substances  or  dried  upon  inanimate  objects^-utensils,  materials, 

^  Loc.  cit.  ^  Archiv.  f.  Exper.  Path.  ii..  Pharmak.,  Bd.  xix.,  S.  420. 

^  Centralblaitf.  Bakteriologie  u.  Parasitenkunde^  Bd.  viii. 

*  Medical  Record,  vol.  xxxi.,  1887. 

^  Centralblaitf.  Bakteriologie  u.  Parn^teiikunde,  Bd.  xi.,  No.  25. 

®  Loc.  cit.         ''   De  V influence  de  la  lumiere  sur  les  inicro-organismes,  Lyon,  1888. 


36  TYPHOID   FF.VKR. 

etc. — they  rctiiin  their  vitality  lor  inaiiy  months.  In  dust  aiul  in 
saiul,  as  well  as  in  earth,  the  bacilli  persist  for  several  weeks  (ITflel- 
maun  ').  The  same  has  been  demonstrated  by  various  observers  for  the 
soil,  in  which  the  bacilli  have  been  found  to  retain  their  vitality  for  as 
long  as  five  and  a  half  months.  It  is,  liowcvcr,  to  be  emphasized 
expressly  that  no  competent  observer  has  noticed  niiiltii)lication  of  the 
bacilli  in  the  soil,  a  fact  that  is  directly  opposed  to  the  gratuitous  assump- 
tion of  the  adherents  of  the  ground- water  theory  that  maturation, 
development,  and  reproduction  of  the  typhoid  virus  take  place  in  the 
soil,  and  therefore  one  Avhich  renders  untenable  an  essential  feature  of 
this  doctrine. 

Among  the  drying  exi)eriiiients,  those  of  Seitz,^  Uffelniann/  Gaffky/ 
and  Schiller^  are  especially  instructive.  While  the  last-named  two  observed 
the  bacilli  to  retain  their  vitality  for  several  mouths,  and  even  for  a  year, 
on  threads  of  silk,  etc.,  under  suitable  couditions,  the  former  observed  the 
bacilli  to  persist  from  two  to  three  months  dried  directly  upon  cloth. 

Of  decisive  importance  is  the  question  with  regard  to  the  persistence 
of  typhoid-bacilli  in  water,  the  answer  to  which  is  complicated  and 
difficult.  The  simplest  problem,  from  which  many  investigators  started 
out,  is  the  behavior  in  distilled  water  or  in  sterilized  spring- water,  well- 
water,  or  river- water.  Under  these  conditions,  m  the  absence  of  extremes 
of  temperature  and  of  other  extraneous  disturbing  influences,  it  has  been 
determined  that  the  bacilli  may  persist  for  as  long  as  three  months.  The 
interesting  circumstance  has  developed — as  it  had  previously  been  estab- 
lished also  for  other  micro-organisms — that  a  difference  in  the  vitality 
of  the  bacilli  is  exhibited  as  the  water  in  question  is  at  rest  or  in 
movement.  In  the  latter  event  the  bacilli  are  more  quickly  destroyed.^ 
The  conditions  are  far  different  in  unsterilized  drinking-water,  river- 
water,  or  household- water,  and  therefore  water  under  ordinary  conditions. 
In  this  connection  it  may  be  stated  at  the  outset  that  the  possibility  of 
preserving  the  bacilli  varies  widely  in  accordance  with  the  different 
cheraic  and  biologic  peculiarities  of  the  respective  waters.  From  this 
point  of  view  it  is  conceivable,  and  it  has  repeatedly  been  demonstrated 
practically,  that  in  some  waters  the  vitality  of  the  bacteria  is  exceedingly 
slight,  wliile  in  others  it  may  be  considerable.  Of  far  greater  impor- 
tance than  physical  and  chemic  conditions  in  this  connection  are  the 
presence  and  activity  of  water-bacteria.     Nevertheless,  the  bacteria  have 

'  Centralblaft  f.  BaktericAogie  u.  Pnrasitenkunde,  Bd.  xv. 

^  Loc.  cit.  ^  Loc.  cit.  *  Loc.  cit. 

^  Arbeiteii  aus  clem  Peichs-Gestmdheitsatnt,  Bd.  v. 

^  Di  Mattliai  ed.  Stugnitta,  Annali  deW  histltuto  d'Igiene  sperimentale  di  Rotna,. 
1889. 


ETIOLOGY.  37 

been  found  to  retain  their  vitality  for  as  long  as  eighty  days  in  by  no 
means  ideal  drinking-water  (Chantemesse  and  Widal,'  Strauss  and 
Dubarry  ^).  Even  in  greatly  contaminated  flowing  water,  as,  for 
instance  the  Panke  at  Berlin,  which  was  examined  by  Wolfhiigel 
and  Riedel,^  the  bacilli  were  found  to  retain  their  vitality  and  still  to  be 
capable  of  multiplication  at  high  temperatures  (16°  C.  and  above).  The 
germs  were  observed  to  retain  their  vitality  for  as  long  as  three  weeks 
in  river-mud  and  in  the  sediment  from  wells. 

That  the  conditions  are  more  favorable  in  this  connection  in  the 
usually  well-protected  general  and  house  reservoirs  is  from  the  outset 
undoubted  and  especially  to  be  noted  in  investigations  into  the  mode  of 
dissemination  of  the  disease.  We  are  indebted  to  Chantemesse  for  pre- 
cise experimental  evidence  in  this  connection.  The  investigations  have 
been  extended  also  to  artificially  prepared  and  especially  carbonated 
waters,  which  in  times  of  epidemic  may  play  an  important  role  as  pre- 
sumably innocuous  substitutes  for  ordinary  drinking-water.  Typhoid- 
bacilli  have  been  found  to  retain  their  vitality  in  them  for  days  and 
even  for  weeks.*  Other  ordinary  fluids,  and  especially  bouillon,  have 
already  been  mentioned  as  good  preserving  and  nutrient  media  for  the 
bacilli.  Not  less  important  in  this  connection  also  is  milk,  and  to  this 
detailed  reference  will  be  made  later.  In  this  place  it  may  be  mentioned 
that  the  bacilli  retain  their  vitality  in  boiled  milk  for  as  long  as  three 
months  and  more 

Finally,  a  word  may  be  said  with  regard  to  the  persistence  of  the 
typhoid-bacilli  in  the  intestinal  discharges.  This  is  in  general  and  under 
ordinary  conditions  not  inconsiderable.  With  a  moderate  external 
temperature  and  a  feebly  alkaline  reaction  of  the  stools  the  bacilli  have 
persisted  for  more  than  three  months  (Karlinski '"),  while  they  die  more 
rapidly  when  the  external  temperature  is  low,  as  well  as  when  the  stools 
are  of  highly  acid  reaction,  or  in  the  presence  of  ammoniacal  decomposi- 
tion, such  as  occurs  especially  when  the  stools  are  mixed  with  urine.  In 
the  dried  stools  the  bacilli  retain  their  vitality  for  a  far  longer  period 
than  under  the  conditions  just  named,  and  this  naturally  is  of  especial 
importance  with  regard  to  the  dissemination  of  the  disease. 

All  of  the  individual  statements  hitherto  made  indicate  that  the 
typhoid-bacillus,  in  spite  of  the  absence  of  spore-formation  and  in  spite  of 
a  certain  sensitiveness  to  individual  influences  (high  degrees  of  tempera- 

•'  Gazette  hebd.  de  medecine  et  chirurgie,  1887,  No.  9. 

^  Archives  de  medecine  exjjh^iinentale^  Bd.  i. 

'  Arbeiten  aus  devi  knis-Gesundheitsamt^  Bd.  v.,  1886. 

*  Hochstetter,  Arbeiten  ausdem  Reichs-Gesundheitsavit,  Bd.  vi.,  1887.         ^  Loc.  cit. 


38  TYPHOID  FEVER. 

turc  and  direct  sunlight),  exhibits  a  tenacity  \vithin  and  without  the 
body  that  wholly  suffices  to  constitute  the  basis  of  the  pi*incij)al  etiologie 
factors  heretofore  recognized,  lender  the  most  varied  ordinary  con- 
ditions (not  hiduccd  experimentally)  the  bacillus  is  capable  of  surviving 
for  days,  weeks,  and  months,  and  even  for  more  than  a  year,  and  under 
favorable  conditions  even  throughout  the  winter.  An  additional  con- 
clusion is  permissible — namely,  that  not  alone  the  persistence  of  the 
germs,  but  also  their  dissemination  through  the  media  named,  is 
certain.  If  in  this  connection  the  liquid  media  in  general  pre- 
dominate, the  dry  media  are  not  to  be  left  out  of  consideration.  It 
cannot  be  denied  that  the  contagium  attached  to  particles  of  dust  may 
be  disseminated  through  the  air  to  a  limited  degree.  AVe  shall  later 
have  an  opportunity  to  return  to  the  more  common  and  practically 
important  methods  of  dissemination. 

HOW  DO  THE  TYPHOID-BACILLI  GAIN  ACCESS  TO  THE 
BODIES  OF  THE  INDIVIDUALS  INFECTED? 

Almost  all  physicians  are  agreed  at  the  present  day  that  the  digestive 
tract,  as  it  appears  especially  to  furnish  the  contagium,  also  is  in  turn  by 
far  the  most  frequent,  even  the  almost  exclusive,  portal  of  entr}"  for  it. 
The  conviction  is  held  at  the  present  day  that  typhoid  fever  is  not  trans- 
missible in  the  sense  of  the  "  true  contagious  "  diseases,  as,  for  instance, 
typhus  fever,  scarlet  fever,  and  measles.  Mere  presence  in  the  vicinity 
of  the  patient  is  never  sufficient  for  infection,  as  with  the  latter.  The 
lungs  and  the  skin,  the  most  probable  portals  of  entry  for  the  acute 
exanthemata,  are  scarcely  to  be  taken  into  consideration  in  connection 
w'ith  typhoid  fever.  If,  in  spite  of  this  flict,  infection  through  inhalation 
seems  possible  in  rare  cases,  it  will  Ijc  found  upon  more  careful  investi- 
gation that  here  also  the  poison  has  gained  entrance  through  the  digestive 
tract.  Under  such  circumstances  the  infection  is  conveyed  through 
finely  divided  fluid  containing  bacteria  or  infectious  particles  of  dust, 
which,  although  they  have  gained  entrance  into  the  mouth  with  inspired 
air,  are  then  swallowed  and  have  thus  commenced  their  action  in  the 
intestine. 

The  ]n'iiicij)al  manner  in  which  the  poison  gains  entrance  into  the 
body,  and  as  compared  with  which  all  others  are  scarcely  to  be  taken 
into  consideration,  consists  in  swallowing  the  infective  agent,  either  in 
consequence  of  accidental,  specific  contammation  of  the  buccal  cavity  and 
its  surrounding  structures,  or  through  the  introduction  of  food  and  drink 
containing  the  typhoid-bacillus.      From    the    mouth   the   virus    passes 


ETIOLOGY.  39 

through  the  esophagus  and  stomach  mto  the  intestine,  in  the  feebly  alka- 
line contents  of  which  are  furnished  conditions  favorable  for  its  further 
development.  The  bacilli  appear  soon  to  pass  from  the  lumen  of  the 
bowel  into  its  wall,  with  especial  preference  for  the  lymphatic  apparatus. 
From  this  point  they  migrate  to  the  related  lymphatic  glands,  and 
thence  through  the  blood-stream  to  the  tissues  and  organs  that  have 
been  repeatedly  pointed  out  as  especially  containing  the  bacilli. 

For  a  comprehension  of  the  processes  of  infection  themselves,  and  in 
consideration  of  the  experiences  that  have  been  had  with  other  patho- 
genic organisms,  particularly  the  cholera-bacillus,  the  question  is  impor- 
tant as  to  hoAV  the  typhoid-bacilli  behave  with  relation  to  the  gastric 
juice.  It  is  from  the  outset  to  be  expected  that  the  typhoid-bacilli, 
which  thrive  even  upon  feebly  acid  nutrient  media,  will  more  readily 
pass  through  the  stomach  uninjured  than  the  cholera-bacilli,  which  are 
especially  sensitive  to  the  action  of  acids.  As  a  matter  of  fact,  both  prac- 
tical and  experimental  observations  show  that  the  bacilli  of  Eberth  are 
relatively  resistant  to  the  secretion  of  the  stomach,  so  that  they  may 
leave  this  viscus  with  their  vitality  preserved,  especially  if  admixed 
with  certain  articles  of  food.  The  free  hydrochloric  acid  need  alone  be 
taken  into  consideration  as  exerting  a  deleterious  influence.  Pepsin  has 
proved  to  be  absolutely  harmless  for  the  bacilli  (Strauss  and  Wurtz  ^). 

After  Kitasato  ^  had  demonstrated  the  relative  resistance  of  the  typhoid- 
bacilli  to  acids,  Seitz^  showed  that  in  a  dilution  of  hydrochloric  acid,  0.3  part 
to  1000,  the  micro-organisms  retained  their  vitality  for  three  days.  In  a 
dilution  of  0.9  part  to  1000  they  were  found  destroyed  hy  Strauss  and 
Wurtz  only  after  from  two  to  three  hours;  and  Chanteniesse  and  Widal* 
showed  that  slight  acidification  with  hydrochloric  acid  did  not  entirely  inhibit 
development  of  the  cultures.  Stern  ^  and  Hamburger,"  who  took  up  the  ques- 
tion anew,  likewise  came  to  the  conclusion  that  the  protection  afforded  by  the 
hydrochloric  acid  of  the  gastric  juice  against  the  entrance  of  typhoid-bacilli 
is  very  doubtful. 

On  account  of  the  quite  rapidly  increasing  number  of  cases  reported  as 
typhoid  without  intestinal  lesions,  the  question  arises  whether  infection  can 
occur  through  any  other  tract  than  the  intestinal,  or  whether  the  bacilli 
may  invade  the  body  by  passing  through  the  normal  intestine  without  causing 
any  lesion  in  that  tract.  In  regard  to  the  first  possibility,  there  is  no  proof 
at  present  that  such  a  mode  of  infection  can  ever  occur.  The  cases  without 
intestinal  lesions  have  lately  been  reviewed  by  Opie.'  He  concludes  that 
the  number  of  cases  is  too  small  to  justify  the  assertion  that  typhoid-bacilli 

'  Archives  de  medecine  experimentale,  1889. 

*  Zeitschr.  f.  Hygiene,  Bd.  vii.  *  Loc.  eit. 

*  Archives  de  Physiologie,  1887. 

*  Volkmann's  Sammlung  klin.  Vortr.,  Neue  Folge,  No.  138. 

*  Inaug.  Dissertation,  Breslau,  1890,  under  the  direction  of  Stern. 
'  Bull.  Johns  Hopkins  Hosp.,  vol.  xii. 


40  TYrilOID  FEVER. 

can  ever  enter  throiiirh  an  absolutely  intact  intestinal  wall,  yet  even  in  fatal 
cases  the  intestinal  lesions  may  be  so  slight  as  not  to  be  recognized  at  the 
time  of  autopsy. 


THE   MOST    IMPORTANT    CARRIERS    AND    MODES    OF 
DISSEMINATION   OF    THE  VIRUS. 

Among  the  carriers  of  tiie  virus,  water  is,  according  to  the  present 
state  of  knowledge,  by  far  the  most  im])ortaut.  Even  since  the  earliest 
times  water  has  played  an  important  role  in  the  minds  of  both  the  laity 
and  the  medical  profession  in  the  development  of  most  infectious  diseases. 
Only  for  a  time  have  theories  now  abandoned  rendered  doubtful  its 
significance  in  regard  to  typhoid  fever.  Earlier  authors,  especially 
Dupre,  Budd,  Murchison,  and  Griesinger,  emphasized  the  importance 
of  water,  however  widely  their  etiologic  views  diverged  in  other  respects. 
After  them  the  dissemination  of  the  disease  through  water  Avas  main- 
tained by  Gietl,^  Biermer,^  and  Liebcrmeister,^ — by  the  latter  with  a 
critical  description  of  small  and  large  epidemics.  The  fact  that  these 
views  were  held  at  that  time,  notwitlistanding  the  deficient  knowledge 
of  the  cause  of  the  disease,  A\ill  ever  remain  an  example  of  scientific 
acumen. 

The  results  of  modern  bacteriologic  investigation,  already  fully  con- 
sidered, have  permanently  established  the  role  of  water,  and  have 
besides  pcmiitted  a  deeper  hisight  into  the  innumerable  and  extremely 
variable  conditions  amid  which  it  may  serve  as  the  carrier  and  dissemi- 
nator of  the  typhoid  virus.  It  is  known  that  the  water  of  streams, 
brooks,  and  springs,  of  conduits,  of  wells,  of  cisterns  and  reservoirs,  of 
ponds,  the  bilge-water  of  ships,  may  contain  the  typhoid-bacillus  in  a 
living  state,  and  under  favorable  conditions  may  even  permit  its  further 
development.  That  this  development  is  imperilled  in  flowing  water, 
that  the  presence  of  a  preponderant  number  of  water-bacteria  or  jiutre- 
factive  agents  is  capable  of  destroying  the  bacilli,  is  naturally  not  con- 
tradictory to  the  "  water-theory,"  but  rather  furnishes  important  data 
for  explaining  the  variability  of  the  occurrence,  the  severity,  and  the 
distribution  of  the  disease. 

The  forms  in  which  water  may  serve  as  the  means  of  conveying  the 
noxious  germ  to  human  beings  are  in  detail  so  extremely  variable  that 
they   cannot  all  even  be  mentioned  in  this  place.     Every  individual 

1  Die  Ursacheyi  des  Enierogenen  Typhus  in  Mundien^  Leipsic,  1865. 
^  Volkmann's  Sammhwff  kiln.  V(rrir.,  No.  53. 
'  GesammeUe  Abhandlungen,  S.  27-65. 


ETIOLOGY.  41 

case,  endemic  or  epidemic,  carefully  studied  in  this  connection  exhibits 
peculiar  and  in  part  new  conditions,  and  the  most  varied  relations  with 
others  long  known.  The  simplest  and  certainly  the  most  frequent 
occurrence  consists  in  infection  through  drinking-water  and  liquid  as 
well  as  solid  articles  of  food  that  are  prepared  without  adequate  steril- 
ization. Water  used  for  cleansing  and  other  domestic  pui-poses  can 
naturally  not  be  separated  from  drinking-water.  Under  these  circum- 
stances also  there  is  direct  or  indirect  specific  contamination  of  materials 
that  gain  entrance  into  the  digestive  tract. 

The  manner  in  which  the  water  in  question  becomes  contaminated 
by  the  dejections  of  typhoid  patients  naturally  exhibits  the  greatest 
diversity.  It  may  receive  the  germs  directly  from  the  patient  or  from 
privy-wells  or  cesspools,  or  through  articles  specifically  contaminated 
accidentally,  or  it  may  be  infected  indirectly  by  previous  saturation  of 
the  adjacent  earth  with  fluids  containing  the  germs.  Even  in  the  pre- 
bacteriologic  period  numerous  careful  observations  bearing  upon  this 
point  were  made,  among  which  a  number  could  be  directed  with  remark- 
able positiveness,  in  the  sense  of  Budd  and  of  Gietl,  against  the  simple 
putrefactive  theory  of  Murchison  and  his  predecessors  and  successors. 
In  this  category  are  included,  for  instance,  those  cases  in  which 
wells  that  for  a  long  time  were  demonstrably  contaminated  with  the 
overflow  from  cesspools  caused  no  or  only  general  bad  effects  upon 
the  consumers  of  the  water,  and  only  gave  rise  to  the  development  of 
typhoid  fever  after  the  water  had  been  specifically  infected  with  the 
dejections  from  a  case  of  typhoid  fever. 

In  the  nature  of  things,  well-infections  are  confined  to  a  few  cases  or 
to  smaller  or  larger  house-epidemics.  Less  commonly,  when  liquid 
articles  of  food  used  on  a  large  scale  (as,  for  instance,  milk,  or  solid 
articles  of  food)  are  infected  by  means  of  water,  will  a  larger  number  of 
cases  arise  directly  from  wells.  Not  rarely  infection  occurs  indirectly  if 
those  directly  infected  convey  the  disease  to  other  localities  where  new 
foci  of  infection  develop.  Endemics  of  considerable  extent  and  even 
epidemic  distribution  are  naturally  more  readily  caused  through  the 
intermediation  of  larger  and  smaller  rivers,  streams,  brooks,  and  springs. 
The  relation  of  these  to  the  development  and  dissemination  of  typhoid 
fever  was  established  much  later  than  that  of  wells.  Many  large 
epidemics  which  at  the  present  day  can  be  definitely  traced  to  this 
mode  of  origin  were  for  a  long  time  used  to  support  other  theo- 
ries, the  pythogenic,  the  atmospheric,  the  earth-theory,  or  the  ground- 
water theory.  The  inference  was  made  that  prior  to  the  outbreak  of 
the  epidemic  there  was  no  typhoid  patient  throughout  the  community 


42  TYPHOID  FEVER. 

or  ill  its  vicinity.  How  else,  tliereloiv,  could  the  disease  have  arisen 
except  through  autochthonous,  local  development  of  infectious  matters  ? 
Were  not  especially  the  conditions  of  the  soil  and  their  variations 
under  the  influence  of  the  ground-water  decisive  as  an  etiologic  factor  ? 
It  was  overlooked  that  the  water-ways  conveyed  the  specific  poison  from 
long  distances ;  that  broolcs  and  streams  niiglit  bo  infected  through  their 
tributaries ;  and  that  upon  larger  w^ater-Avays  ships  were  capable  of 
importing  the  infectious  material  from  remote  points. 

Typhoid  fever  became  most  widely  disseminated  in  large  cities  in 
which  the  water  used  for  drinking  and  other  domestic  purposes,  imper- 
fectly or  not  at  all  filtered,  was  obtained  from  large  streams  that  cou- 
stimtly  served  as  receptacles  for  the  contents  of  the  sewers  of  these 
cities  themselves  or  of  those  of  neighboring  cities. 

All  of  these  factors,  it  must  be  emphasized,  to  counteract  the  influ- 
ence of  the  few  remaining  but  persistent  opponents  of  the  theory  of 
typhoid  fever  as  a  water-borne  disease,  are  in  no  wise  hypothetic.  The 
demonstration  of  typhoid-bacilli  in  the  water  of  wells  and  streams  has 
often  been  made  directly,  and  their  persistence  in  these,  as  has  been 
pointed  out,  is  undoubted.  That  the  bacilli  have  not  been  found  in  the 
suspected  water-supply  in  every  endemic  or  epidemic  is  not  contradictory 
of  this  view.  Thus,  it  has  been  re})eatedly  observed  that  in  a  given 
locality  the  typhoid-bacillus  was  evidently  obtained  from  a  cei-tain  source. 
Efforts  were  made  further  to  obtain  proof  that  a  focus  of  typhoid  fever 
had  existed  at  a  higher  level ;  but  when  examination  of  the  water  was 
undertaken,  the  primary  focus  of  infection  had  already  been  extinguished. 
It  may  also  be  readily  conceded  that  it  is  by  no  means  always 
possible  to  demonstrate  the  presence  of  typhoid-bacilli  even  in  water 
that  still  contains  them.  Especially  greatly  contaminated  water  con- 
tains numerous  other  micro-organisms,  which  may  render  identification 
of  the  typhoid-bacillus  difficult  and  even  impossible  even  for  an  experi- 
enced observer.  It  should  be  noted  especially  that  the  distribution  of 
the  bacilli,  particularly  in  connection  with  certain  forms  of  pollution,  is 
by  no  means  uniform.  They  are  often  attached  to  isolated,  irregularly 
distributed  particles,  so  that  only  extremely  time-consuming  and  pains- 
taking investigation  of  large  amounts  of  water  will  yield  approximately 
trustworthy  results. 

The  literature  of  all  countries  from  the  beginning  of  the  nineteenth  cen- 
tury until  recent  time  contains  a  large  number  of  reports  of  epidemics, 
some  given  with  full  detail,  induced  by  infection  of  wells,  springs,  and 
streams.  Limitations  of  space  alone  will  not  permit  extended  consideration  of 
these.    They  have  been  collected  in  part  by  Murchison,  Gietl,  and  Griesinger  ; 


ETIOLOGY.  43 

also  Liebermeister '  and  Biermer^  have  given  numerous  bibliographic  refer- 
ences in  their  works,  which  so  brilliantly  and  definitely  established  the 
drinking-water  theory.  As  an  illustration  of  well-iiifection  the  following 
observation  may  suffice  :  In  the  early  part  of  the  seventies  1  treated  a 
number  of  typhoid  fever  patients  living  in  a  suburb  of  Berlin  upon  a  large 
estate  which  included  almost  1000  inhabitants,  who  were  crowded  together 
in  small,  poorly  ventilated  rooms.  My  investigations  disclosed  that  at  the 
same  time  about  80  other  patients  were  under  treatment  either  at  home  or  in 
hospitals.  Further  inquiry  revealed  that  the  water  derived  from  the  only 
well  upon  the  place  (the  general  water-supply  had  not  yet  been  extended  to 
this  locality)  was  greatly  polluted  by  organic  material,  was  turbid,  and 
offensive  to  the  sense  of  smell.  A  year  previously  the  water  presented 
similar  characters,  and  the  cause  was  found  to  consist  in  a  communi- 
cation between  a  large  cesspool  and  the  well.  My  opinion  that  such  con- 
tamination of  the  water  by  the  contents  of  the  cesspool  still  existed  and 
must  be  the  cause  of  the  typhoid  fever  was  met  by  the  statement  on  the 
part  of  responsible  individuals  that  in  the  previous  year,  when  the  water 
was  similarly  contaminated,  there  had  been  no  typhoid  fever  in  the  com- 
munity. Further  investigation  disclosed  that  this  was  correct,  but  also 
revealed  a  condition  which  explained  the  apparent  difference  and  con- 
verted my  suspicion  into  certainty— ^namely,  that  four  weeks  before  the 
occurrence  of  the  first  cases  of  typhoid  fever  among  the  inhabitants  of  this 
section,  a  boy  had  arrived  in  the  place,  in  whom  symptoms  of  typhoid  fever 
soon  appeared,  and  from  whom  two  children  in  the  family  with  whom  he 
lived  were  infected.  There  was  thus  no  longer,  as  in  the  previous  year,  only 
general  pollution  of  the  well  with  fecal  material,  but  an  admixture  with 
specific  germs,  the  essential  condition  for  the  development  of  the  disease. 
A  most  instructive  instance  of  dissemination  of  the  poison  through  the 
water-supply  is  furnished  by  Liebermeister.^  In  the  village  of  Lausen,  in 
which  for  a  long  time  only  isolated  cases  of  typhoid  fever  imported  from 
Basle  had  occurred,  and  for  seven  years  no  case  at  all,  in  the  year  1872, 
among  800  inhabitants,  130,  almost  17  per  cent.,  were  attacked  between  the 
months  of  August  and  October.  The  epidemic  set  in  so  abruptly  that 
almost  100  cases  occurred  within  the  first  three  weeks.  A  number  of 
persons  also  who  were  only  temporarily  resident  in  Lausen  were  attacked. 
Careful  investigation  disclosed  that  all  of  the  houses  of  the  village  that 
obtained  their  water  from  pump-wells  were  exempt  from  the  disease,  which 
invaded  only  those  whose  water-supply  was  obtained  from  running  springi;. 
"With  regard  to  these,  it  was  determined  that  a  small  brook  that  constituted 
their  source  was  contaminated  by  the  overflow  from  a  cesspool  and  a  manure- 
pit  attached  to  a  house  some  distance  above  the  village,  and  in  Avhich  there 
had  been  four  cases  of  typhoid  fever  during  the  months  of  June,  July,  and 
August. 

'  Cited  by  Liebermeister :  Zuckschwert,  Die  Typhus  epidemie  i7n  Waisenhnifse  zu 
Halle  a.  S.  im  Jahre  1871,  Halle,  1871.  N.  Bansen,  Veher  Aetiologie  des  Typhus 
abdominalis,  Ziiricher  Dissertation,  Winterthur,  1872  (Typhus  in  Winterthur).  Com- 
pare also,  concerning  the  same  epidemic,  Weinmann,  Correspondenzhl.  f.  Schiv.  Aerzte, 
1872,  No.  23. 

'^  Biermer,  Loc.  cit.  Weissflog,  "  Ueber  die  Typhus  Epidemie  zu  Elterlein  von 
1872,"  Deutseh.  Arch.  f.  kiln.  Med.,  1873,  Bd.  xii.,  S.  320.  Kiichenmeister,  "  Der 
Reinhardtsdorfer  Typhus,  1872-73,"  Allg.  Zeit.  f.  Epidein.,  B.eft  1.  A.  Erismann, 
Correspondenzhl.  f.  Schw.  Aerzte,  1873,  No.  10.     Quincke,  Ibid.,  1875,  No.  8. 

^  Loc.  cit.,  S.  64. 


44  TYPHOID  FEVER. 

An  instance  of  the  developmont  and  e})idemic  distribution  of  typlioid 
fever  on  a  large  scale  from  a  large  stream  is  furnished  by  the  conditions 
that  prevailed  in  Hand)urg  in  the  eighties.  In  the  years  1885,  1886,  1887, 
and  1888,  1,5,804  ])ersons  were  attacked  by  typhoid  fever,  with  1214  deaths. 
As  is  known,  Hamburg,  until  the  great  cholera-epidemic  demanded  even 
more  urgently  than  typhoid  the  necessity  of  a  change  in  its  water-sup])ly, 
derived  all  of  its  water  for  drinking  and  domestic  i>ur{)oses  from  the  river 
Elbe,  which  was  conveyed  into  the  houses  untiltered  and  employed  for  all 
economic  and  commercial  purposes  without  jirevious  disinfedion.  Almost 
the  only  water  filtered  was  that  used  for  drinking  and  culinary  purposes,  but 
it  was  done  with  apparatus  that,  as  is  now  known,  was,  by  reason  of  its 
defective  construction,  calculated  rather  to  exert  an  injurious  effect  than  to 
subserve  the  purpose  for  which  it  was  employed.  Even  at  that  time  I 
contended  that  the  development  of  the  epidemic  was  attributable  in  greater 
degree  to  the  obviously  specifically  infected  water-supply  than  to  all  other 
influences.'  I  based  my  opinion  especially  upon  the  arrangement  of  the 
sewerage-system  of  Hamburg,  the  contents  of  which,  poured  into  the  Elbe, 
were  capable  of  causing  infection  of  the  drinking-water,  likewise  obtained 
from  the  Elbe,  because  the  point  at  which  the  sewage  was  emptied  and 
that  from  which  the  water  was  obtained  were  not  sufficiently  separated. 
Especially  was  it  in  the  highest  degree  probable,  and  even  demonstrated 
by  the  experiments  of  Simmonds,  that  the  reflux  wave  induced  with 
the  flood-tide  of  the  Elbe  carried  the  material  emptied  from  the  sewers 
up  to  and  beyond  the  point  from  which  the  water-supply  was  obtained. 
From  the  uniform  distribution  of  typhoid  fever  throughout  the  entire  inner 
citv  also  it  was  concluded  that  a  uniformly  distributed  carrier  of  the  poison 
was  oi^erative.  This  could  scarcely  be  anything  else  than  the  water-supply. 
Even  in  the  eyes  of  the  most  fanatic  adherents  of  the  localization-theory  the 
conditions  of  the  soil  and  the  ground-water  could  not  seriously  be  taken  into 
consideration  in  a  city  that  for  a  long  time  had  been  provided  with  a  model, 
extensive,  intricately  ramifying,  and  excellently  working  system  of  sewerage. 
Additional  positive  evidence  was  found  in  the  fact  that  in  the  neighboring 
city  of  Wandsbeck,  immediately  contiguous  to  Hamburg,  and  whose  inhabi- 
tants live  under  identical  external  conditions,  and  the  same  conditions  of 
soil,  climate,  and  weather,  there  were  only  a  few  cases  of  typhoid  fever 
during  the  same  period.  The  only  point  of  difference  between  the  two  cities 
was  in  the  water-supply,  Wandsbeck  obtaining  its  water  not  from  the  Ham- 
burg supply  and  not  from  the  Elbe.  Still  more  characteristic  was  the 
existence  of  an  almost  completely  immune  collection  of  buildings  within  a 
portion  of  the  city  of  Hamburg,  in  which  typhoid  was  as  severe  and  as 
obstinate  as  in  the  remaining  parts.  The  barracks  in  that  section  occupied 
by  the  Seventy-sixth  Infantry  Regiment,  which  contained  in  its  young, 
vigorous  members  material  in  most  marked  degree  predisposed  to  the  disease, 
remained  free  from  the  epidemic,  wnth  the  exception  of  a  few  obviously 
imported  cases.  .  It  was  not  connected  with  the  general  water-supply,  but 
received  all  of  its  drinking  and  other  water  from  a  well  uyion  the  premises. 
The  soil  and  ground-water  theories,  however,  at  that  time  so  thoroughly 
dominated  the  minds  of  those  in  authority  that  my  opinions  and  recom- 
mendations^ fell  ujjon  deaf  ears.  Subsequently  the  relations  in  question 
were  investigated  by  Reinke,  and  my  previously  expressed  views  were  fully 
confirmed  and  amplified   by  a  large   number  of  carefully  established  facts. 

1  DeuUc.h.  med.   Woch.,  1888. 

^  Deidsch.   Vierlelj.  f.  offentl.  Gesundheitspflege,  Bd.  xxviii.,  Heft  3. 


ETIOLOGY.  45 

The  earlier  inference  that  with  every  flood-tide  the  water  of  the  Elbe  between 
the  point  of  discharge  of  the  sewage  and  the  source  of  supply  for  the  water, 
and  even  far  beyond,  contained  an  increased  number  of  germs,  was  removed 
beyond  doubt  by  Dunbar.'  Then  Reinke  demonstrated  by  tables  the  fact, 
to  which  I  had  already  directed  attention,  that  those  f)ortions  of  the  city  that 
received  their  water-supply  from  the  common  source  were  almost  uniforndy 
attacked  by  the  epidemic,  while  the  most  peripheral  districts  f  Winterhude, 
Eppendorf,  and  Horn),  which  at  that  time  did  not  share  equally  in  the 
blessings  of  the  common  supply,  exhibited  correspondingly  and  strikingly 
fewer  cases.  The  clearest  confirmation,  however,  is  afforded  by  a  considera- 
tion of  the  conditions  in  Hamburg  since  the  time  (May,  1893)  when  the 
source  of  water-supply  was  removed  a  considerable  distance  further  up  the 
stream  and  when  the  water  itself  was  subjected  to  adequate  filtration  before 
it  reached  the  city.  For  the  years  1894  and  1895  the  morbidity  of  typhoid 
fever  was  462  and  597  respectively. 

The  following  table  of  Reinke  is  more  eloquent  than  words : 

Number  of  cases.  Number  of  deaths. 


Year.  Absolute        To  1000  of  the      Absolute      To  1000  of  the 

number.  population.         number.        population. 

884       1053  2.35  108  0.24 

885 2172  4.65  160  0.34 

886 3890  8.09  333  0.69 

887 6543  13.26  446  0.90 

888 3199  6.23  275  0.54 

889 3172  5.89  222  0.41 

890 1539  2.73  147  0.26 

891 1197  2.06  128  0.22 

892 1941  3.30  203  0.35 

893 1094  1.84  106  0.18 

Change  in  the  source  of  supply  and  introduction  of  filtration. 

894 462  0.76  37  0.06 

895 597  0.96  57  0.09 

It  is  further  interesting  and  distinctive  that  more  than  one-tenth  of  the 
cases  of  typhoid  fever  in  Hamburg  noted  in  the  years  1894  and  1895  did 
not  occur  in  the  area  supplied  with  good  water,  but  were  observed  upon 
ships,  on  which  it  develops  in  consequence  partly  of  infection  of  the  bilge- 
water,  partly  of  importation  from  elsewhere.  Reinke  properly  emphasizes, 
besides,  the  danger  of  ships,  to  which  typhoid  fever  is  so  indigenous,  with 
relation  to  infection  of  the  river-water,  and  also  the  water  of  other  navi- 
gable streams.  The  Hamburg  epidemic  well  illustrates  the  operation  of 
a  large  vicious  circle  :  Infection  of  sewage  with  typhoid-bacilli,  conveyance 
of  these  by  the  flood-tide  to  the  source  of  water-supply,  distribution  of  the 
infected  water  throughout  the  entire  city,  as  a  result  rapid  multiplication 
of  the  typhoid-bacilli  in  the  contents  of  the  sewers,  and  through  these  a 
progressive  increase  in  the  number  of  bacteria  in  the  water-supply.  It  was 
not  until  the  year  1893  that  the  unfortunate  circle  was  interrupted  by 
changing  the  place  for  discharge  of  the  sewage  and  the  erection  of  suitable 
filtration-plants. 

In  addition  to  water,  various  liquid  articles  of  food  have  already  been 
designated  as  carriers  of  the  typhoid  contagium.  Of  these,  milk  is 
deserving  of  especial  consideration.  Milk  is  a  source  of  infection 
naturally  not  in  the  same  way  as  in  the  case  of  that  from  tuberculous 

^  Cited  by  Eeinke. 


46  TYPHOID  FEVER. 

auiinals,  wliero  it  is  infected  directly  by  them,  and  so  contributes  to  the 
disseniiuatiou  of  tuberculosis.  Typlu)id  fever  is  not  known  with 
certainty  to  occur  in  animals.  The  role  of  milk  as  a  carrier  of  infection 
rather  resembles  that  of  "water,  directly  admixed  with  Avhieh  or  other- 
wise infected  it  exhibits  its  injurious  activity.  The  experiences  of  the 
last  twenty-five  years  have  but  too  often  shown  that  milk,  like  the 
water-supply,  infected  at  its  source  or  at  its  point  of  collection,  may 
through  its  distribution  lead  to  widespread  dissemination  of  ty})hoid 
fever  and  give  rise  to  .small  or  even  to   more  extensive  epidemics. 

Both  in  the  unboiled  and  in  the  boiled  state  milk  is  an  admirable 
preservative  and  nutrient  medium  for  typlioid-bacilli,  which  persist  in 
sterilized  milk,  according  to  the  experimental  observations  of  Heim,^  for 
more  than  thirty  days,  and,  what  is  especially  dangerous,  they  do  not 
cause  coagulation,  and  do  not  change  the  milk  in  other  respects  (see 
previous  observations)  m  appreciable  degree.  In  all  well-observed 
epidemics  of  typhoid  fever  due  to  milk  the  same  series  of  events,  modified 
in  details,  is  repeated  :  Infection  of  the  bulk  of  milk  supplied  by  the 
producer  for  distribution,  through  well-water  or  spring-water  to  which, 
directly  or  indirectly,  the  dejections  from  typhoid  patients  have  gained 
entrance.  AX,  times  the  cases  of  the  disease  have  been  found  at  a 
distance  from  the  farm,  far  above  the  course  of  the  supplying  springs, 
and  at  other  times  in  the  dairy  itself. 

The  special  modes  of  infection  of  milk  are  various  :  Dilution  with 
the  infected  water,  jireservation  and  transportation  in  vessels  rinsed  with 
such  water,  or  direct  infection  through  the  hands  of  milkers,  dealers, 
servants,  and  other  persons  who  have  come  in  contact  with  typhoid 
patients  and  their  dejections,  and  who,  having  neglected  suitable  pre- 
cautions, have  conveyed  the  germs  directly  to  the  udder,  the  milk,  or 
the  vessels. 

Naturally,  other  articles  of  food  obtained  from  dairies  and  milk- 
depots  may,  similarly  to  milk,  act  as  the  carriers  of  infection.  Butter 
especially,  in  which  Heim  ^  found  the  bacilli  to  persist  for  twenty-one 
days,  and  the  different  kinds  of  cheese,  in  which  the  bacilli  may  persist 
from  one  to  three  days  in  accordance  with  the  method  of  manufacture, 
may  act  in  this  way. 

As  early  as  the  seventies  reports  of  milk-infection  were  made  in  England, 
following  which  an  extensive  literature  developed.  As  an  instance,  a  severe 
epidemic  of  typhoid  fever  in  the  year  1873,  in  the  district  of  St.  George's, 
Hanover  Square,  Marylebone,  London,  may  be  mentioned.'     It  soon  devel- 

'  Arbeit,  a.  d.  kniferl-Gesimdheitsamte,  Bd.  v.  *  Loc.  cit. 

"  Gueneaud  de  Mussy,  Pub.  de  I' Acad,  de  Med.,  1881. 


ETIOLOGY.  47 

oped  that  servants  and  especially  children,  who  were  in  the  habit  of  drinking 
the  milk  from  a  certain  well-known  dairy,  were  attacked  in  large  numbers. 
A  commissioner,  who  was  entrusted  with  the  investigation  of  the  dairy,  found 
nothing  suspicious  ;  and  a  second,  who  reached  a  like  result,  endeavored 
further  to  establish  the  harmlessness  of  the  milk  by  himself  partaking 
thereof.  He  paid  the  penalty  of  his  experiment  with  iiis  life,  inasmuch  as 
he  died  shortly  afterward  from  a  severe  attack  of  typhoid  fever.  The 
establishment  was  closed,  and  the  epidemic  soon  subsided.  Its  mode  of 
development  was  now  shown  to  be  as  follows :  The  well  with  the  water  from 
which  the  dairy-man  rinsed  his  vessels,  and  probably  also  diluted  their 
contents,  communicated  with  the  soil  contaminated  by  an  adjacent  dung-heap 
upon  which  had  been  thrown  the  dejections  from  a  case  of  typhoid  fever  in 
the  dairy. 

Cameron^  observed  numerous  cases  of  typhoid  fever  in  Dublin  in  those 
houses  in  a  given  district  that  received  their  milk  from  a  certain  dairy,  while 
the  houses  that  derived  their  milk  from  other  establishments  remained 
exempt.  It  appeared  that  in  the  dairy  first  mentioned  infection  of  the  milk 
had  resulted  through  3  cases  of  typhoid  fever.  An  epidemic  observed  by 
v.  Mehring,  and  described  by  Schmidt,^  is  interesting,  having  occurred 
among  the  inmates  of  two  prisons  ofStrassburg,  as  a  result  of  the  use  of 
unboiled  milk.  This  was  obtained  from  a  place  in  which  cases  of  typhoid 
fever  had  occurred,  and  the  disease  subsided  as  soon  as  the  supply  of  milk 
from  this  source  was  cut  off.  The  etiologic  interpretation  of  this  epidemic  is 
materially  strengthened  by  the  fact  that  the  persons  involved  were  almost,  as 
in  an  experiment,  cut  off  from  general  intercourse  with  others,  and  were 
exposed  to  identical,  thoroughly  controlled  conditions.  Further  instructive 
instances  of  milk-infection  are  recorded  also  by  Almquist,^  Roth,*  Reich,* 
Goyon,   Bouchereau'  et  Fourail,**  All  Cohen,'  and  others. 

In  contrast  with  milk,  certain  articles  of  drink  are  in  repute  among 
the  laity  as  capable  of  diminishmg  the  danger  of  infection.  With  this 
idea  the  suspected  water  is  in  times  of  epidemic  mixed  with  tea,  coffee, 
or  alcohol,  or  the  use  of  alcoholic  beverages  instead  of  water  is  recom- 
mended. With  reference  to  tea  and  coffee,  it  may  briefly  be  stated  that 
so  far  as  their  chemic  constitution  is  concerned  they  have  no  deleterious 
effect  upon  the  typhoid-bacilli.  With  regard  to  spirituous  liquors,  the 
experiments  of  Pick  ^  have  shown  that  while  they  are  capable  of  exert- 
ing a  certain  destructive  effect  upon  the  typhoid-bacilli,  this  is  by  no 
means  so  active  as  it  is  upon  cholera-vibrios.  The  bacilli  are  generally 
not  destroyed  in  ordinary  white  or  red  table-wine  earlier  than  after  half 
an  hour,  and  at  times  even  later.  Addition  of  wine  to  water  cannot, 
therefore,  serve  as  a  prophylactic.  Lager  beer  and  other  light  beers 
exerted    no    bactericidal    effect    within    a    reasonably   practical    time— 

1  See  Brouardel  et  Thoinot,  p.  54.  ^  Inaug.  Diss.,  Halle,  1893. 

^  Deutsch.   Viertelj.f.  off.  Gesundheit.,  Bd.  xxi.  *  Ibid.,  Bd.  xxii. 

^  Berlin,  klin.   Woch.,  1894,  No.  30.  ^  ji^^   d'hyg.  et  de  Pol.  sanit.,  1892. 

^  Weckbl.  V.  h.  Nederl.  Tijdschr.  voor  Genesk.,  1887,  Bd.  ii. 

^  Arch.  f.  Hyg.,  Bd.  xix. 


48  TYPHOID  FEVER. 

nearly  half  an  hour.  The  action  dI"  [Stronger  alcoholic  beverages 
naturally  is  comparatively  more  pronounced.  Thus,  Pick  observed  tlie 
bacilli  to  be  destroyed  in  rye  whiskey  within  five  minutes.  AMien,  how- 
ever, an  equal  aniount  of  water  was  added,  a  half-lK)ur  elapsed  before 
this  result  was  brought  about.  The  last  experiment  indicates  that  also 
the  stronger  beers  and  wines,  especially  the  sweet  wines,  Mould  be 
unreliable  with  reference  to  their  destructive  etVect  upon  the  typhoid- 
bacilli. 

If  the  commercial  relations  with  reference  to  other  articles  of  food 
are  subjected  to  close  scrutiny,  dangers  similar  to  those  that  attend  the 
use  of  milk  will  readily  become  ajiparent.  They  are,  however,  less 
under  control,  because  the  contamination  is  often  accidental  and  difficult 
of  demonstration,  and  not,  as  with  milk,  systematic  and  often  re]ieated, 
and  because,  accordingly,  rather  isolated  cases  or,  under  certain  circum- 
stances, widely  disseminated,  small  and  therefore  less  conspicuous  foci 
develop.  It  is  quite  clear  and  by  no  means  sufficiently  appreciated  that 
typhoid  fever  may  be  disseminated  from  establishments  from  which 
vegetables  and  greens,  especially,  however,  fruit,  lettuce,  and  similar 
articles  generally  eaten  in  an  uncooked  state,  are  obtained,  if  these 
articles  be  rinsed  or  sprinkled  with  infected  water.  Not  less  important 
is  direct  infection  of  these  articles  of  food  by  typhoid  patients  who  live 
in  these  establishments  or  by  those  in  attendance  upon  the  patients. 
That  bread  and  cake  and  many  other  articles  eaten  without  being  again 
cooked  or  heated  may  be  a  source  of  danger  in  a  similar  manner  does 
not  require  further  elaboration. 

It  need  only  be  noted  that  vegetable-gardeners,  before  going  to  market, 
sprinkle  their  wares  with  water  in  order  to  keep  them  fresh  ;  and  considera- 
tion should  be  given  to  the  especial  danger  if  these  are  transported  in  large 
amounts  by  vessels  upon  large  streams,  which,  as  we  have  seen,  are  so  fre- 
quently infected.  Finally,  attention  should  be  directed  to  the  conditions 
that  prevail  in  the  dwelling-rooms,  the  salesrooms,  and  the  storage-rooms  of 
dealers  in  vegetables  and  articles  of  food,  and  the  manner  in  which  these  are 
crowded  together  in  basements  in  large  cities  anrl  comminiicate  directly  with 
one  another.  On  account  not  alone  of  typhoid,  bnt  also  of  other  infectious 
diseases,  should  sanitary  supervision  and  regulation  of  these  conditions  he 
more  thorough  than  has  hitherto  been  customary. 

Naturally,  typhoid  fever  may  develop  in  any  private  dwelling 
through  direct  or  indirect  infection  of  articles  of  food,  and  be  conveyed 
elsewhere,  the  latter  occurring  especially  if  the  members  of  the  family  or 
the  servants  take  part  in  nursing  the  patient  and  also  in  domestic  work, 
especially  cooking.  The  conditions  are  most  serious  in  this  connection 
among  the  poorer  classes,  but  also  among  those  better  situated  almost 
incredible  things  will  be  done  from  want  of  knowledge  and  owing  to 


ETrOLOGY.  49 

improper  arrangements.  Also  in  hospitals  dissemination  of  typhoid 
fever  occurs  if  the  most  scrupulous  care  be  not  given  to  the  cleanliness 
of  the  patient  and  his  vicinity,  as  well  as  to  the  disinfection  of  the  dis- 
charges, and  if  in  addition  the  attendants  fail  to  observe  the  most  rigid 
precautions.  Most  thorough  disinfection  of  the  hands  and  clothing, 
strict  prevention  of  nurses  engaged  in  the  care  of  typhoid  patients  from 
aiding  in  the  care,  especially  the  feeding,  of  others,  are  especially 
important  considerations  in  this  connection. 

Even  among  the  better  classes,  not  to  speak  of  those  less  favorably 
situated,  the  physician  cannot  take  for  granted  that  thorough  disinfection  of 
the  hands  will  be  practised  and  appropriate  precautions  with  regard  to  the 
care  of  the  clothing  of  the  attendants  will  be  observed.  The  fewest  of 
mothers  or  nurses,  in  going  from  the  sick-bed  to  the  dining-room,  think  of 
changing  their  clothing  or  washing  their  hands  so  thoroughly  as  to  exclude 
the  possibility  of  conveying  disease-germs  to  articles  of  food  and  drink. 
Insufficient  care  in  disinfection  is  certainly  the  most  frequent  means  by 
which  physicians  and  nurses  acquire  the  disease.  With  regard  to  the  latter, 
I  have  always  been  struck  with  the  fact  that  especially  new  nurses,  there- 
fore those  who  from  carelessness  or  lack  of  skill  do  not  observe  the  nece^ 
sary  precautions,  are  more  commonly  attacked  than  older  and  better-trained 
nurses. 

TRANSMISSION  THROUGH  THE  AIR. 

Reference  has  already  been  made  to  the  relation  of  the  air  to  the 
contagium  of  typhoid  fever.  It  was  pointed  out  that  dissemination  of 
the  contagium  through  the  air  is  possible,  whether  the  carrier  be  in  a 
moist  condition  or  in  a  dry  state  in  the  form  of  dust.  The  first  mode 
of  infection  requires  little  consideration.  It  would  be  operative  almost 
exclusively  in  the  event  of  a  spraying  of  infected  fluid  and  its  accidental 
entrance  into  the  mouth  of  a  susceptible  individual.  Less  commonly, 
indifferent  fluids  in  the  form  of  spray  might  carry  the  contagium  attached 
to  dust  for  a  considerable  distance,  a  possibility  in  favor  of  which 
Lassime  ^  has  presented  evidence.  Far  more  commonly  in  practice  the 
possibility  of  dissemination  of  the  contagium  by  particles  of  dust 
must  be  taken  into  consideration.  Reference  has  already  been  made  to 
the  persistence  of  tyjDhoid-bacilli  in  a  dry  state.  The  entrance  of  the 
contagium  disseminated  through  the  air  will  occur  preferably  through 
inhalation,  the  germs  being  deposited  first  m  the  mouth  and  the  nose. 
Entrance  into  the  body  and  the  blood-stream,  however,  probably  takes 
place  only  through  the  digestive  tract.  Whether  entrance  of  the  bacilli 
may  take  place  also  through  the  respiratory  apparatus  is  still  a  debatable 
question.  It  is  certain  that  entrance  by  this  route  would  constitute  the 
exception  (pneumotyphoid  ?).     Nevertheless,  the  observations  of  Buchner^ 

1  These,  Paris,  1890. 
4 


50  TYPllOID  FEVER. 

\\\\\v\\  furnish  oxjiorlniontnl  cvidenco   in  favor  of  this  mode  of  infection, 
are  wortliy  of  eonsideration  anil  eontirniation. 

No  more  can  be  said  from  the  pret;ent  point  of  view  with  regard  to  the 
dissemination  of  typhoid  fever  throuirli  the  air.  Its  rule  lias  become  a  more 
subordinate  one  in  comparison  with  that  assigned  to  it  in  earlier  tinies,  when 
especially  the  impertect  differentiation  of  typhus  and  typhoid  fever  favored 
this  view.  Although  clearness  ])revails  in  this  connection  at  the  present  day, 
another  earlier  view  has  not  been  wholly  eliminated  from  the  minds  of 
inaccurate  imlividuals,  which  for  a  long  time  constituted  the  strongest  su])port 
for  the  doctrine  of  the  dissemination  of  typhoid  fever  through  the  air,  namely, 
that  air  contaminated  by  putrid  substances  is  capable  of  causing  typhoid 
fever  directly,  or  at  least  of  acting  as  the  carrier  of  the  contagium.  At  the 
present  day  it  is  no  longer  held  that  putrid  substances  of  themselves,  espe- 
cially the  decomposition-products  of  feces,  constitute  the  exciting  ageiit  of 
typhoid  fever,  and  the  oj)inion  of  ]>udd  that  the  specific  ty])hoi(l  germ  under 
these  conilitions  finds,  at  least,  its  esj)ecial  paltulum  has  also  been  abandoned. 
To-day  we  recpiire  tlie  demonstration  of  other  etiologic  factors  than  formerly, 
when,  with  the  a[)pearance  of  typhoid  fever,  the  discovery  that  foul  air  from 
an  adjacent  cesspool  or  other  focus  of  putrefaction  entered  the  dwelling  was 
deemed  fully  sufficient  to  explain  the  cause  of  the  outbreak. 

It  would  naturally  be  going  too  far  to  ignore  entirely  the  large  num- 
ber of  cases  reported  by  reliable  early  investigators  in  which  it  Avas 
believed  that  the  contagium  was  disseminated  by  contaminated  air. 
Some  of  these,  it  cannot  be  denied,  are  susceptible  of  scarcely  any  other 
interpretation.  INIore  recent  histories  of  similar  character  would  natu- 
rally be  judged  by  an  entirely  different  standard.  At  the  present  day  it 
Mould  be  necessary  to  demonstrate  that  the  air  in  question  was  laden 
with  active  typhoid  contagium,  and  that  the  conditions  for  its  move- 
ment and  the  entrance  of  the  poison  into  the  body  were  especially  favor- 
able. As  an  instance  of  the  lack  of  precision  in  earlier  observations,  a 
personal  experience  and  the  history  of  two  epidemics  from  the  well- 
known  work  of  Murchison  will  suffice. 

At  the  beginning  of  the  seventies,  in  a  boarding-school  in  Berlin,  in  which 
6  young  persons  occupied  a  large,  well-situated  bedroom,  1  of  these  was 
attacked  with  severe  typhoid  fever,  and  was  sent  by  me,  on  account  of  his 
companions,  all  of  whom  remained  well,  to  the  hospital.  Official  examina- 
tion of  the  case  disclosed  the  presence  upon  one  wall  of  the  room  of  a  moist, 
offensive-smelling  spot,  resulting  from  a  leak  in  a  broken  discharge-pipe  in 
the  wall.  Neither  in  the  house  in  question  nor  in  the  adjoining  house,  as  I 
was  able  to  convince  myself,  had  there  been  a  case  of  typhoid  fever  within  a 
long  time.  Nevertheless,  the  pi]5e  and  the  spot  upon  the  wall  had  to  he 
considered  a.s  the  source  of  the  disease.  My  objection  that  the  remaining  5 
inmates,  of  about  the  same  age  and  equal  predisposition,  had  remained  well, 
and  that  the  disease  of  the  sixth  might  have  been  acquired  elsewhere  from  a 
third  source,  was  received  only  with  a  sympathetic  shrug  of  the  shoulders. 

Also,  the  well-known  and  much-(jUote(l  epidemic  of  typhoid  fever  in  the 
school   for  hoys   attached  to  the  Colchester  Union  in  London '  loses  most 

1  See  Murchison,  loc.  cit. 


ETIOLOGY.  61 

of  its  force  on  more  careful  scrutiny.  In  that  instance  many  of  the 
pupils  in  a  schoolroom  that  communicated  with  a  sewer  by  means  of  the 
chimney  were  attacked  with  a  severe  acute  disease,  which  was  most  intense 
and  appeared  earliest  in  those  seated  nearest  the  chimney.  Murchison 
had  no  doubt  that  the  disease  was  typhoid  fever,  and  that  it  resulted  from 
the  inhalation  of  injurious  gases  from  the  chimney  in  question.  The 
inhalation  as  the  cause  of  the  disease  is,  from  Murchison's  description,  most 
probable,  and  almost  certain  from  the  objective  point  of  view  ;  but  how 
could  Murchison  know,  without  seeing  any  of  tlie  patients,  that  the  disease 
was  typhoid  fever  ?  Only  from  the  fact  that  the  school-inspector  informed 
him  that  in  the  opinion  of  the  attending  physician  the  symptoms  of  the 
disease  resembled  those  described  by  Jenner  as  the  symptoms  of  typhoid 
fever. 

Still  less  convincing  is  the  well-known  epidemic  at  the  school  of  Clap- 
ham,  likewise  cited  by  Murchison.'  In  the  summer  of  1892,  of  22  boys  in 
that  institution,  20  were  seized  within  three  hours  with  "ileotyphoid,"  with 
vomiting,  diarrhea,  and  prostration.  The  disease  was  attributed  to  the  fact 
that  the  boys  had  witnessed  the  reopening  of  a  grave  closed  for  many  years, 
the  greatly  decomposed  contents  of  which  had  been  then  spread  upon  the  soil  in 
the  neighborhool  of  the  playground  of  the  school.  Two  of  the  affected  boys 
died,  one  after  an  illness  of  twenty-three  and  the  other  after  an  illness  of 
twenty-five  hours.  The  autopsy  disclosed  acute  swelling  of  Peyer's  patches 
and  the  solitary  follicles,  with  slight  ulceration  of  one  of  these  structures, 
together  with  enlargement  of  the  mesenteric  glands.  The  question  at  once 
arises  in  connection  with  this  report :  Is  it  not  unusual  that  young,  previously 
healthy  individuals  die  from  typhoid  fever  within  from  twenty-three  to 
twenty-five  hours  ?  Can  the  anatomic  conditions  found  develop  in  a  case  of 
typhoid  fever  within  the  time  mentioned?  Is  the  sudden,  almost  simul- 
taneous, illness  of  the  pupils  suggestive  of  typhoid  fever?  Are  vomiting, 
diarrhea,  and  prostration  evidences  of  this  disease  ?  Do  not,  rather,  all  of 
these  circumstances  indicate  simple  intoxication  with  sewer-gas,  which  in 
fact  was  at  first  suspected  by  the  observers?  Such  conditions  have  been 
recognized,  and  it  is  known  from  the  experiments  of  Magendie,  Leuret  and 
Hammond,  Barker,  and  others,  that  they  can  be  induced  experimentally  in 
animals  by  the  inhalation  of  putrid  gases.  It  has  been  learned  from  the 
experiments  of  Stich^  that  animals  poisoned  by  the  intravenous  injection  of 
putrid  substances  exhibit  intestinal  lesions  identical  with  those  of  the  boys 
at  Clapham,  namely,  intense  catarrh  of  the  lower  portions  of  the  intestine, 
especially  the  ileum,  with  acute  swelling  and  even  exfoliation  of  Peyer's 
patches  and  the  solitary  follicles,  as  well  as  consecutive  hyperplasia  of  the 
related  mesenteric  glands. 

SIGNIFICANCE  OF  EARTH  IN  THE  ETIOLOGY* 

Earth  has  played  as  miportant  a  7'6le  as  air  as  a  carrier  and  dissemi- 
nator of  the  typhoid  poison  in  the  views  of  physicians  and  in  the  litera- 
ture. It  was  considered  as  the  essential  medium  for  the  storing  up  and 
the  further  development  of  the  poison,  which  was  believed  to  originate 
spontaneously  in  it  from  putrid  substances,  or,  accordmg  to  the  view  of 
Budd  and  his  disciples,  to  be  deposited  as  a  specific  contagium  and  there* 

1  Lancet,  1829,  vol.  xvi.  ;   Med.  Gaz.,  vol.  iv.  ^  Charite  Annalen,  1853. 


52  TYPHOID  FEVER. 

io  iiiulci'ijo  multiplication.  It  is  characteristic  of  earlier  epidemiologic 
views  that  this  tliouivht,  which  was  evolved  theoretically  from  certain 
general  experiences,  was  utilized  as  a  secure  basis  for  all  further  conclu- 
sions. In  this  way  were  exphiined  both  the  smallest  as  well  as  the 
most  extensive  epidemics.  If  typhoid  fever  occurred  in  a  house,  or  on 
an  estate,  or  in  a  larger  area,  only  the  infected  subsoil  was  taken  into 
consideration,  provided  that  contaminated  air  was  not  operative.  If  in 
addition  the  swampy  character  of  the  earth  or  the  proximity  of  dung- 
heaps  and  sewers  was  established,  or  if  the  earth  had  been  strewai  with 
refuse  and  manure  a  shorter  or  a  longer  time  previously,  all  doubt  was 
removed.  Xt-,  the  nature  of  the  contugimn  was  unknown,  and  as  this 
"svas  considered  rather  as  gaseous  than  cor|iuscular,  it  was  possible  to 
continue  the  construction  of  hypotheses  without  hindrance.  The  air  was 
then  especially  considered  as  the  vehicle  for  the  poison  in  question,  and 
it  wtis  believed  that  this  escaped  from  the  soil  in  conse({uence  of  a  sort 
of  evaporation,  and  was  then  further  distributed.  If  it  was  possible  to 
show  further  that  the  soil  had  been  turned  up  in  the  neighborhood,  and 
that  shortly  before  excavations  had  been  made,  foundations  dug,  or 
drain-pipes  laid,  the  transference  of  the  infected  ground-air  to  the  w'ork- 
men  and  others  seemed  demonstrated  as  m  an  experiment. 

During  the  great  typhoid  fever  epidemics  of  Hamburg,  some,  unfor- 
tunately influential,  easily  satisfied  individuals  explained  the  occurrence 
beyond  doubt  by  the  fact  that  large  excavations  and  building  operations 
were  in  progress  about  the  harbor.  That  typhoid  was  distributed  over  the 
entire  city,  while  the  excavations  in  question  were  confined  to  a  narrow 
section  and  that  the  adjoining  streets  were  by  no  means  especially  aflfected, 
failed  to  affect  the  preconceived  opinion. 

The  soil-theory  received  its  scientific  development  through  the  well- 
known  w^orks  of  Buhl  and  Pettenkofer,  and  these  dominated  the  theory 
of  the  origin  of  typhoid  fever  until  within  the  most  recent  times.  The 
ground-water  theory  of  Buhl  and  Pettenkofer  was  based  upon  the  sta- 
tistical observation  that  the  morbidity  and  mortality  of  typhoid  fever  in 
Munich  rose  when  the  ground-water  was  at  a  low  level,  w^hile  a  corre- 
sponding reduction  ensued  with  a  rise  in  the  ground-w^ater.  Petten- 
kofer believed  that  he  w^as  able  to  give  a  definite  explanation  for  his 
observations,  namely,  that  the  specific  typhoid  poison  develops  and 
undergoes  maturation  in  the  deeper  layers  of  the  earth  saturated  with 
substances  capable  of  undergoing  putrefaction.  When  the  ground- 
water is  at  a  high  level  this  dangerous  layer  of  the  soil  is  covered  by 
the  former,  and  is  thus  cut  f)ff  from  the  surface  of  the  e<irth,  while  w-hen 
the  ground-water  occupies  a  low  level  this  exclusion  is  wanting.  In 
the  latter  event,  with  the  aid  of  special  local,  seasonal,  and  personal 


ETIOLOGY.  53 

conditions,  the  contagium  might  not  be  prevented  from  escaping  through 
the  ground-air/  when  it  would  be  taken  up  into  the  body  by  inhalation, 
and  in  those  predisposed  would  act  as  the  excitant  of  the  disease. 

The  theory  of  Pettenkofer  aroused  active  opposition  soon  after  its 
announcement,  and  this  in  part  was  based  upon  the  experiences  in  other 
cities  where  the  rise  and  the  fall  of  the  ground-water  bore  no  relation  to 
variations  in  the  prevalence  of  typhoid  fever,  and  in  part  was  directed 
against  the  theoretical  conclusions  of  that  distinguished  hygienist. 
Among  the  earliest  attacks  may  be  mentioned  the  papers  of  Lieber- 
meister  ^  and  Biermer,^  which  are  even  to-day  models  of  critical  utiliza- 
tion of  all  that  was  known  at  the  time.  These  impaired  the  stability 
of  Pettenkofer' s»  theory,  which,  in  the  light  of  present  knowledge,  has 
no  longer  the  significance  that  was  attached  to  it  by  its  author  and  his 
pupils.  With  regard  to  the  statistical  observations,  these  are,  it  is  true, 
applicable  to  the  city  of  Munich ;  but  it  has  been  demonstrated  that 
they  are  not  applicable  to  a  number  of  other  cities,  and  they  are  cer- 
tainly not  susceptible  of  general  application. 

With  relation  to  the  behavior  of  the  typhoid  poison  in  the  soil,  accord- 
ing to  the  view  of  Pettenkofer,  the  knowledge  confirmed  experimentally 
that  the  bacilli  of  Eberth  are  capable  of  retaining  their  vitality  in  the 
earth  for  a  long  time — better  in  porous  than  in  rocky  or  otherwise  imper- 
vious soil — might  be  emphasized.  Grocher  and  Dechamps  observed 
them  to  persist  for  five  and  a  half  months  at  the  depth  of  |  meter. 
This  resistance  is  probably  not  greatly  diminished  by  cold  and  dr^-ness 
(see  p.  35),  so  that  the  poison  may  under  favorable  circumistances  sur- 
vive in  the  earth  both  through  the  cold  as  well  as  the  heated  season. 
The  conditions  are  different,  however,  with  regard  to  the  hypothetic 
maturation  and  propagation  of  the  bacilli  in  the  earth.  The  first,  in 
accordance  with  existing  knowledge,  is  not  at  all  probable  or  is  so  in 
but  limited  degree.  Any  considerable  multiplication  of  the  bacilli  in 
the  earth  or  any  increase  in  their  virulence  is  wholly  undemonstrated. 
In  any  event,  these  things  do  not  occur,  as  a  rule.  Also,  definite  local 
or  seasonal  conditions  exerting  a  favorable  influence  in  this  connection 
have  not  been  clearly  demonstrated. 

Even  if  the  other  opinions  of  Pettenkofer  were  better  supported,  his 
hypothesis  that  the  poison  finds  its  way  into  the  air  from  the  earth  and 
is  disseminated  in  this  way  would  be  most  difficult  of  demonstration. 
This  would  be  conceivable  of  a  gaseous  poison.     The  known  corpus- 

1  See  Pettenkofer,  Veber die LuftimBodenundGrundluft,  Braunschweig,  1873. 
''■  Ges.  Abhandlungen  u.  Ziemssen's  Hand.buch,  1  Aufl.,  Bd.  i. 
*  Volhnann^ s  Sammlung  klin.  Vortr.^  1873. 


54  TYPHOID  FEVER. 

cular  nature  of  the  coutiigium  is,  however,  directly  opposed  to  sueli  a 
view.  Only  in  exee})tional  instances,  attachetl  to  particles  of  dust  act- 
ino;  as  carriers,  could  it  jniiu  access  to  the  botlv  directlv  from  the  earth 
and  cause  infection.  Thus,  it  is  conceivable  that  in  the  course  of  excii- 
vations  and  other  operations  n})on  infected  soil,  germ-containing  dust 
might  gain  direct  entrance  into  the  mouth  and  thence  into  the  digestive 
tract  of  the  workmen  thus  engaged  and  cause  infection,  and  that  the 
individutds  thus  infected  might  cause  further  dissemination  of  the  dis- 
ease. Even  in  these  cjises,  however,  the  probability  of  infection  through 
the  soiled  hands,  clothing,  articles  of  food,  etc.,  is  still  greater  than 
that  through  inhalation. 

The  principal  mode  of  dissemination  of  typhoid  fever  from  subsoil 
containing  typlioid-bacilli  will  always  remain  that  through  water,  a 
medium  to  which  the  believers  in  the  localization-theory  attached  far 
too  little  importance  from  the  outset.  From  all  that  is  as  yet  known, 
water  is  by  far  best  adapted  to  take  up  the  bacillus  from  the  eartli  and 
to  effect  its  further  dissemination.  The  germ  may  thus  find  its  way 
into  flowing  water,  or  under  favorable  conditions  gain  entrance  from  the 
subsoil-water  into  wells,  or  be  washed  out  of  the  upper  layers  of  the 
earth  by  rain  and  melted  snow. 

INFECTION    AND    DISSEMINATION    THROUGH    HOUSE- 
HOLD ARTICLES. 

References  to  this  subject  have  already  been  made.'  In  view  of  the 
practical  importance  thereof,  it  seems  desirable^  however,  to  return  to 
it  at  greater  length.  Undoubtedly,  the  typhoid  poison  may  remain 
attached  in  an  active  state  for  a  considerable  length  of  time  to  clothing, 
linen,  bedding,  and  various  household  articles.  Under  such  circum- 
stances these  articles  are  generally  contaminated  directly  or  indirectly 
through  the  dried  dejections  from  typhoid  patients.  Naturally,  under 
these  circumstances  the  family  of  the  patient,  the  attendants,  laundresses, 
and  other  persons  whose  occupation  requires  that  they  come  in  contact 
with  the  articles  in  question  are  most  exposed  to  danger.  Infection  is, 
however,  frequently  brought  about  indirectly  through  healthy  inter- 
mediaries, who  remain  well,  and  who  may  convey  the  poison  attached 
accidentally  at  the  bedside  to  their  clothing  or  their  hands ;  and  without 
doubt  a  number  of  cases  of  obscure  etiology  are  attributable  to  such 
occurrences.     Naturally,  physicians    should  always  bear  in  mind  that 

'  See  the  statements  on  pp.  35  and  '-'A)  with  regard  to  the  persistence  of  the  Eberth 
bacillus  under  varvino;  conditions  of  desiccation. 


ETIOLOGY.  55 

they  may  themselves  be  tlie  means  of  conveying  typhoid  fever,  in  the 
same  way  as  some  otlier  infectious  diseases,  by  failure  to  observe 
adequate  precautions.  There  is  no  doubt  that  inf(!ction  may  tiii\e  place 
at  a  distance  by  the  transmission  in  infected  utensils. 

A  number  of  years  ago  the  following  instructive  experience  occurred  to 
nie  :  A  young  merchant  living  in  middle  Germany,  \vh(j  wan  accustomed  to 
send  a  portion  of  his  clothing  and  linen  to  his  home  in  Hamburg  to  he  laun- 
dered, continued  this  practice  when  attacked  with  "gastric  fever."  Ten  and 
twelve  days  respectively  after  the  sister  of  the  patient  and  a  servant  had 
washed  the  linen,  they  became  ill,  the  one  with  a  mild,  the  other  with  a 
severe  attack  of  typhoid  fever.  That  the  brother  had  also  suffered  from  the 
same  disease  was  unfortunately  demonstrated  by  autopsy,  death  occurring 
from  copious  intestinal  hemorrhage  in  the  course  of  an  apparently  mild 
attack.  While  the  mode  of  infection  just  mentioned  is  by  no  means  rare 
for  the  acute  exanthemata,  especially  variola  and  typhus  fever,  and  in  the 
acute  infectious  diseases  most  closely  allied  to  them,  and  must  be  taken  into 
consideration  in  cases  of  obscure  origin,  little  or  no  reference  is  made  to  it 
in  the  literature  or  in  practice  in  connection  with  typhoid  fever.  The  same 
thing  happened  with  regard  to  this  as  occurred  with  a  number  of  other  cir- 
cumstances of  etiologic  importance.  They  were  all  neglected  or  ignored  for 
a  long  time  from  the  custom  of  looking  at  all  things  from  the  point  of  view 
of  the  pythogeuic  or  the  subsoil-theory. 


FACTORS    THAT    FAVOR  INFECTION  AND  DISSEMINA- 
TION OF  THE  DISEASE. 

Having  thus  far  occupied  ourselves  with  the  direct  causes  of  typhoid 
fever — that  is,  with  the  peculiarities  of  its  specific  contagium,  especially 
its  vital  relations,  the  various  possibilities  of  its  multiplication,  dis- 
semination, and  invasion  in  the  human  body — we  shall  now  take  up  the 
contributory  factors,  namely,  those  that  are  of  importance  for  the  recep- 
tion of  the  poison  into  the  body,  for  its  further  development  therein,  and 
for  its  pathogenic  activity. 

Individual  bodily  conditions  and  acquired  conditions  favoring  the 
development  of  the  disease  are  especially  to  be  taken  into  consideration 
in  this  connection.  Perhaps  with  further  advances  in  Ivnowledge  we 
shall  learn  to  divide  these  influences  into  those  that  lower  the  resist- 
ance of  the  organism  to  the  bacilli  and  those  that  directly  favor  their 
vitality  and  multiplication.  At  the  present  time  but  little  is  known 
concerning  these  matters.  We  have  not  advanced  far  beyond  the 
theoretic  guides  to  the   lines  for  future  investigation. 

A  second  important  group  of  contributory  factors  consists  in  the 
conditions  existing  outside  of  the  body — locality,  climate,  season  of 
the  year,  etc.  Although  these  also  to  a  certain  degree  act  upon 
the    individual,   their   principal    significance,   however,   resides    in    the 


56  TYPHOID  FEVER. 

influence  tliat  tlicv  exert  upon  the  behavior  of  the  poison  deposited 
and  preserved  outside  of  the  body,  upon  its  persistence  and  its  further 
development.  Much  that  has  been  said  with  regard  to  the  tenacity 
of  the  poison  is  apphcable  in  this  connection.  On  the  whole,  our 
present  knowledge  in  this  field  is  based  rather  u])on  empiric  than 
theoretic,  especially  experiuK'ntal,  grounds. 

FACTORS  RELATING  TO  THE  INDIVIDUAL. 

Age  and  Sex. — The  large  number  of  statistical  data  with  refer- 
ence to  these  subjects,  however  exact  they  may  appear,  must  be  received 
with  great  caution.  Many  are  obviously  not  at  all  in  accordance  with 
the  facts,  while  others  agree  only  on  general  lines.  Most  might  be 
expected  from  extensive  official  statistical  statements,  covering  all  of  the 
inhabitants  of  a  coimtrv,  both  the  well  and  the  sick.  Unfortunately, 
these  suifer  from  variation  in  the  reliability  of  the  diagnosis  and  from 
the  deficiency  in  anatomic  data.  In  hospitals,  on  the  other  hand,  where 
these  conditions  are  the  most  favorable,  other  factors  throw  doubt  upon 
the  statistical  results.  Thus,  there  is  often  the  smallness  of  the  number 
of  cases,  and  almost  everywhere  the  class  of  patients  admitted  to  the 
hospitals  does  not  represent  the  average  population  of  a  community,  and 
therefore  the  real  average  morbidity  is  not  represented.  In  this  con- 
nection it  is  especially  to  be  taken  into  consideration  that  children  and 
married  persons  are  for  obvious  reasons  less  commonly  sent  to  hospitals 
than  unmarried  adults,  mechanics,  laborers,  servants,  visiting  strangers, 
etc.  Of  the  married,  experience  has  also  shown  that  everywhere  the 
women  go  to  the  hospitals  less  commonly  and  defer  entrance  longer 
than  the  men.  In  weighing  the  significance  of  statistical  data  these 
circumstances  should  receive  appropriate  consideration. 

As  to  the  influence  of  ag"e,  there  is  no  doubt  that  youth  especially 
predisposes  to  typhoid  fever,  and  the  period  of  life  between  the  fifteenth 
and  the  thirty-fifth  year  is  by  far  the  most  commonly  attacked.  In 
my  experience  fully  four-fifths  of  all  cases  occur  at  this  period,  and  in 
this  connection  it  should  be  noted  further  that  more  than  half  (about  56 
per  cent.)  occur  between  the  fifteenth  and  the  twenty-fifth  year.  Between 
the  thirtieth  and  thirty-fifth  years  the  number  of  cases  diminishes  some- 
what, to  fall  considerably  between  the  thirty-fifth  and  the  fortieth  year. 
After  the  fiftieth  year  the  morbidity  can  be  expressed  in  fractions  of  1 
per  cent.  In  old  age  the  disease  can  be  considered  as  rare.  Likewise 
in  early  childhood  up  to  the  first  year  of  life  typhoid  fever  is  rare,  as  is 
known  also  of  most  other  acute  infectious  diseases.  From  the  first  to 
the  fifth  year  a  gradual  increase  takes  place.     From  the  fifth  to  the 


ETIOLOGY. 


57 


fifteenth  year  the  predisposition  becomes  still  greater,  so  that  during 
this  period  more  are  affected  than  between  the  thirty-fifth  and  fortieth 
years. 

The  following  figures,  based  upon  observations  made  in  the  hospitals  of 
Hamburg '  and  Leipsic,''  may  serve  to  illustrate  what  has  been  said  : 


Cases 

of  Typhoid 

Fever  in  the  Hamburg 

General  Hospital,   1886-87. 

1886. 

1887. 

Age. 

Male. 

Female. 

Total. 

Percent- 
age. 

Male. 

Female. 

Total. 

Percent- 
age. 

2 

0 

3 

3 

0.2 

1 

3 

4 

0.18 

3    . 

2 

1 

3 

0.2 

3 

3 

6 

0.27 

4    . 

4 

5 

9 

0.6 

7 

0 

7 

0.31 

5    . 

4 

9 

13 

0.9 

3 

2 

5 

0.22 

6    . 

4 

3 

7 

0.5 

0 

6 

6 

0.27 

7    . 

9 

4 

13 

0.9 

3 

6 

9 

0.40 

8    . 

3 

6 

9 

0.6 

9 

9 

18 

0.80 

9    . 

10 

9 

19 

1.3 

16 

9 

25 

1.12 

10    . 

13 

11 

24 

1.7 

11 

15 

26 

1.16 

11    . 

19 

9 

28 

1.9 

13 

9 

22 

0.98 

12    . 

12 

5 

17 

1.2 

22 

21 

43 

1.92 

18    . 

18 

9 

27 

1.9 

25 

19 

44 

1.96 

14    . 

18 

14 

32 

2.2 

21 

11 

32 

1.43 

15-20 

239 

169 

408 

28.2 

412 

280 

692 

30.88 

21-25 

255 

114 

369 

25.5 

418 

205 

623 

27.80 

26-30 

180 

66 

246 

17.0 

249 

107 

356 

15.89 

31-35 

78 

34 

112 

7.8 

114 

43 

157 

7.01 

36-40 

27 

23 

50 

3.5 

51 

26 

77 

3.44 

41-46 

21 

5 

26 

1.8 

37 

18 

55 

2.45 

46-50 

6 

5 

11 

0.8 

13 

2 

15 

0.67 

51-55 

1 

1 

2 

0.1 

4 

7 

11 

0.49 

56-60 

2 

\ 

3 

0.2 

4 

1 

5 

0.22 

61-65  . 

0 

i 

1 

0.1 

0 

0 

0 

0.00 

66-70      . 

0 

0 

0 

0.0 

1 

2 

3 

0.13 

Age  not     ) 
specified.     / 

6 

7 

13 

0.9 

Tota 

1  . 

931 

514 

1445 

100.0 

1437 

804 

2241 

100.00 

1  H.  Schutz,  "  Beitrag  zur  Statistik  des  Abdominal-typhus,"  Jahrb.  d.  Hamburger 
Staats-Krankenansialten,  1889,  1  Jahrg. 

2  C.  Berg.,  Inaug.  Diss.,  Leipsic,  1893. 

Both  of  these  studies  were  made  under  my  direction.  The  dissertation  of  Berg 
follows  the  work  of  Schutz  with  reference  to  the  statistical  questions  considered  and 
the  arrangement  of  the  material.  From  the  year  1889  the  results  are  based  upon 
information  obtained  from  answers  to  a  series  of  questions  that  I  have  introduced  into 
the  Leipsic  hospitals  in  the  same  form  as  used  in  the  Hamburg  hospitals. 


58 


TYPHOID  FEVER. 


An   analysis   of   1626  cases  of  typhoid   fever  in  the    Jacobsspital    of 
Leipsic  between  1880  and  1893  disclosed  the  following  figures : 


Age. 

1880. 

1881. 

1882. 

^          1 

1883. 
0 

1884. 
0 

1885. 
0 

1886. 
0 

1887. 
0 

1888. 
1 

1889. 
1 

1890. 

0 

1891. 
0 

1892. 

1893. 

1 

0 

0 

0 

0 

») 

2 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

3 

0 

0 

0 

1 

0 

2 

0 

0 

0 

0 

0 

2 

1 

1 

4 

0 

2 

0 

0 

1 

3 

1 

0 

1 

0 

2 

0 

0 

0 

5-9 

3 

6 

9 

3 

6 

2 

5 

2 

2 

1 

2 

1 

4 

0 

10-14 

9 

10 

7 

5 

6 

4 

3 

8 

1 

10 

5 

6 

6 

4 

15-19 

25 

32 

14 

25 

28 

30 

24 

23 

17 

50 

36 

32 

18 

5 

20-24 

28 

50 

23 

34 

35 

32 

40 

19 

21 

62 

34 

23 

27 

6 

25-29 

25 

33 

16 

26 

23 

23 

14 

23 

25 

30 

26 

18 

22 

4 

30-34 

8 

16 

9 

8 

18 

10 

8 

12 

7 

15 

15 

20 

7 

4 

35-39 

5 

13 

6 

11 

14 

7 

n 

5 

5 

11 

10 

5 

3 

0 

40-44 

6 

5 

2 

1 

1 

5 

1 

3 

"0 

3 

3 

6 

3 

2 

45-49 

0 

6 

1 

3 

4 

2 

0 

4 

1 

4 

1 

1 

2 

0 

50-54 

1 

3 

0 

3 

1  o 

2 

1 

1 

JO 
(2 

2 

2 

1 

2 

55-59 

1 

0 

0 

1 

1 "" 

0 

0 

1 

0 

60-69 

0 

1 

0 

0 

0 

0 

1 

2 

0 

2 

1 

1 

2 

0 

70-80 

0 

1 

0 

0 

0 

0 

0 

2 

0 
82 

3 

0 

0 
117 

0 

0 

Total. 

113 

178 

88 

121 

138 

120 

110 

103 

194 

137 

97 

28 

Arranged  according  to  ages,  these  fourteen  years  showed  the  following 
relations : 


Age. 

Cases. 

Percentage  of 
all  cases. 

Age. 

Cases. 

Percentage  of 
all  cases. 

1 

2 

3 

4 

5-9    ...    . 
10-14      .    .    . 
15-19      .    .    . 

3 

2 

10 

46 

86 

359 

434 

315 

0.19 

0.13 

0.44 

0.G3 

2.80 

5.40 

22.40 

27.00 

19.50 

30-34  .... 
35-39  .... 
40-44          .    . 
45-49  .... 
50-59  .... 
60-69  .... 
70-80  .... 

Total  .    .    . 

167 
106 
41 
29 
20 
10 
5 

10.40 
6.61 
2.50 
1.80 
1.25 
0.63 
0.32 

20-24      .    .    . 
25-29      .    .    . 

1626 

In  view  of  the  large  number  of  children  (451)  treated  at  Hamburg  in 
1886-87,  it  may  be  profitable  to  consider  these  in  tabular  form  : 


Percentage  of 

1 

Percentage  of 

Age. 

Number. 

children  at- 

!           Age. 

Number. 

children  at- 

tacked. 

tacked. 

2 

7 

1.60 

9 

44 

9.90 

3 

9 

1.85 

10 

50 

11.15 

4 

16 

3.70 

11 

50 

11.30 

5 

18 

4.20 

12 

60 

13.30 

6 

13 

3.30 

13 

71 

15.50 

7 

22 
27 

5.05 
6.30 

14 

Total     .    . 

64 

14.30 

8 

451 

The  table  shows,  as  has  been  indicated,  that  typhoid  fever  is  not  frequent  in 
childhood  until  aliout  the  fifth  year,  when  the  frequency  gradually  increases 
until  the  ninth  year,  then  to  reach  its  height  after  the  tenth  year.  A  com- 
parison with  the  statements  of  recognized  authorities,  as,  for  instance,  Mur- 
chison,'  Fiedler,^  and  Griessinger,^  discloses  agreement  with  the  figures  given. 

'  Die  typhoiden  Krankheiten,  German  by  Ziilzer,  Braunschweig. 

«  Arch.  f.  Heilk.,  1862. 

^  Virchow's  Handbuch  der  speciellen  Paihotogie,  1864,  2  Aufl.,  Bd.  ii. 


ETIOLOGY. 


59 


Thus,  52  per  cent,  of  Murehison's  patients  were  between  fifteen  and  twenty- 
five  years  old.  Fiedler^  reports  that  58.8  per  cent,  of  his  patients  were 
between  the  twentieth  and  the  thirtieth  year  of  aj^e,  while  8.4  per  cent,  were 
above  forty  and  only  0.7  per  cent,  were  more  than  fifty.  The  statistics  of 
Griesinger  also,  dealing  with  more  than  510  cases  observed  in  Zurich 
between  1860  and  1863,  include  20.1  per  cent,  between  the  tenth  and  the 
nineteenth  year,  46.6  per  cent,  between  the  twentieth  and  twenty -ninth 
year,  and  16.8  per  cent,  from  the  thirtieth  to  the  fortieth  year.  The  statis- 
tics of  Liebermeister "  are  particularly  instructive,  as  this  ol)server  carefully 
endeavored  to  avoid  the  statistical  errors  attendant  upon  the  inclusion  of 
hospital-patients : 


Age. 

Number  of 

cases  of 

typhoid  fever. 

Percentage  of 
the  total  num- 
ber. 

Percentage  of 
this  age  in  the 
total  popula- 
tion. 

Predisposition  as 
coinyjared  with 
the  average  repre- 
sented by  1. 

From  16  to  20  years  .    .    . 

323 

19 

12 

1.6 

"      21  "  80     " 

987 

58 

29 

2.0 

a       31   a  40      u 

274 

16 

24 

0.7 

"      41  "  50     ■' 

88 

5 

16 

0.3 

"      51  "  60     " 

30 

2 

10 

0.2 

"      61  "  70     " 

11 

0.6 

6 

0.1 

Above  70  years  .    . 

1 

0.06 

3 

0.02 

The  frequency  of  typhoid  fever  at  various  ages  has  been  estimated  from 
the  mortality-tables  in  a  number  of  works  characterized  by  the  largeness  of 
the  figures.  These  collections  fail  to  give  a  representation  of  the  actual  state 
of  affairs,  as  the  mortality  is  variable  at  different  periods  of  life,  and  some 
periods,  as,  for  instance,  old  age,  exhibit  unusually  high  figures.  Lieber- 
meister therefore  reproduces  the  mortality-statistics  of  Hagenbach  ^  with  the 
same  qualification.  The  following  tabulation  by  Brouardel  *  of  16,036 
cases  is  most  instructive  in  this  connection : 


Deaths  from  Typhoid  Fever  in  Paris  from  1880  to  1889  considered  according 

to  Age. 


Up  to  1  year 36 

From  1  to  5  years 1041 

5  "  10  "   1265 

10  "  15  "   1386 

15  "  20  "   2991 

20  "  25  "   3896 

25  "  30  "   2081 


From  30  to  35  years 1197 

"  35  "  40  "   .  .  .• 771 

"  40  "  45  "   457 

"  45  "  50  "   380 

Above  50  years 535 

16,036 


On  comparing  this  with  the  preceding  table,  it  will  be  seen  that  the 
marked  differences  in  morbidity  are  obliterated  ;  thus,  for  instance,  the 
figures  for  children  between  the  first  and  the  tenth  year  equal  those  for 
persons  between  the  tenth  and  the  fifteenth  year  ;  and  there  is  little  differ- 
ence between  the  ages  from  fifteen  to  thirty ;  while  the  figures  for  old  age 
are  comparatively  high. 

Sex  causes,  apparently,  little  difference  with  regard  to  infection 
with  typhoid  fever.     On  the  whole,  among  adults  men  are  attacked 

1  Loc.  cit.  2  ziemssen's  Handbuch,  3  Aufl.,  Bd.  ii.,  Heft  1,  S.  124. 

^  Jahrb.  d.  Kinderheilk.^  Neue  Folge,  1875,  Bd.  ix. 

*  "Repartition  de  la  fievre  typhoide  en  France,"  Rec.  d.  irav.  Comite  consult, 
d'hyg.,  1891. 


60  TYPHOID  FEVER. 

rather  more  frequently  than  women.  Whether  this  difference  is  due 
actually  to  the  conditions  of  sex  appears  more  than  improbable.  Of 
determinino;  influence  in  the  case  of  men  is  probably  the  greater  oppor- 
tunity foi"  infection,  in  the  presence  of  ecpial  susceptibility,  by  reason  of 
greater  variations  in  residence,  in  nutrition,  and  in  occupation.  That 
these  circumstances  do  not  affect  the  statistics  in  greater  degree  is 
undoubtally  due  to  the  fact  that  the  predominant  influence  of  water  in 
the  dissemination  of  the  disease  affects  women  in  scarcely  less  degree 
than  it  does  men.  IMention  of  the  fact  further  should  not  be  omitted 
that  in  hospital-statistics  males  predominate  somewhat  because  they  enter 
hospitals  more  readily,  and  therefore  with  relatively  greater  frequency. 

If  in  certain  localities  there  is  a  marked  majority  of  cases  in  males,  this 
of  itself  indicates  nothing,  but  rather  requires  investigation  into  the  nature 
of  the  population.  Thus,  for  instance,  it  can  be  understood  that,  in  places 
that  liy  reason  of  large  establishments  or  factories  attract  young  males  in 
especial  number,  this  fact  would  receive  expression  in  the  event  of  an  epi- 
demic of  typhoid  fever  in  the  greater  number  of  males  attacked.  Murchison 
believed  the  two  sexes  equally  susceptible.  Among  2432  cases  treated  in 
the  London  Fever  Hospital  between  1848  and  1861,  there  were  1211  males 
and  1221  females.  Also,  Bartlett'  observed  1179  males  and  1163  females 
among  2312  cases.  Although  Fiedler^  observed  57.6  per  cent,  of  males  and 
42.4  per  cent,  of  females,  this  may  agree  with  the  usual  proportions  of  the 
two  sexes  received  into  the  hospital.  Among  2235  cases  of  typhoid  fever 
observed  in  Hamburg,  I  have  found  2118  males  (65.5  per  cent.)  and  1117 
females  (34.5  per  cent.),  but  feel  justified  in  stating  definitely  that  this 
preponderance  of  males  is  not  the  expression  of  a  difference  in  predisposi- 
tion, but  is  the  result  of  local  conditions,  leading  to  the  admission  of  fewer 
women  into  the  hospital. 

Some  writers  on  pediatrics  (West,  Barthez  and  Rilliet,  Taupin) 
believe  that  the  difference  between  the  sexes  with  relation  to  predis- 
position to  the  disease  extends  into  childhood.  All  observed  that  more 
boys  than  girls  were  attacked.  Although  it  is  not  at  all  clear  how  such 
differences  can  arise  prior  to  the  period  of  sexual  development,  the  fol- 
lowing figures  are  striking :  Barthez  and  Rilliet,  80  boys,  31  girls ; 
Taupin,  86  boys,  35  girls. 

I  believe,  however,  that  these  figures  are  too  small  to  exclude  acci- 
dental influences,  and  that,  therefore,  they  do  not  sustain  the  general 
statements  based  upon  them.  With  a  much  larger  field  for  observa- 
tions, I  have  not  been  struck  by  the  preponderance  of  boys.  Among 
451  children  suffering  from  typhoid  fever,  I  observed  only  a  few  more 
males  than  females,  namely,  250  boys  and  201  girls. 

To  what  degree  accidental  influences  may  be  operative,  even  with  figures 
much  larger  than  those  previously  given,  was  shown  in  considering  sepa- 

^  Cited  by  Murchison.  *  Loc.  cit. 


ETIOLOGY.  61 

rately  for  each  year  the  451  cases  observed  in  children  during  the  years 
1886  and  1887  in  Hamburg.  It  then  appeared  that  in  1886  there  were 
attacked  116  boys  and  88  girls ;  in  1887,  184  boys  and  113  girls. 

Certain  physiologic  conditions  in  women,  as  pregnancy,  the 
puerperal  state,  and  lactation,  appear  to  diminish  tlie  predis- 
position to  typhoid  fever.  With  regard  to  the  degree  of  immunity 
conferred  by  these  states,  not  inconsiderable  differences  of  opinion  exist 
among  various  authorities.  Griessinger  considers  typhoid  fever  exceed- 
ingly rare  in  the  puerperium,  and  he  believes  nursing  infants  also  to  be 
particularly  immune.  In  this  respect  he  is  in  accord  with  Rokitansky. 
I  have  also  observed  typhoid  infection  but  twice  in  the  puerperium, 
and  but  rarely  during  lactation.  With  regard  to  pregnancy,  in  agree- 
ment with  Liebermeister,  I  do  not  believe  that  the  immunity  is  at  all 
considerable. 

In  Hamburg,  among  1117  women  38  were  pregnant — 3.4  per  cent.  In 
my  experience  at  Leipsic  2  per  cent,  were  pregnant.  Even  at  those  periods 
of  life  in  which  the  predisposition  to  the  disease  and  the  chances  of  preg- 
nancy are  diminished,  the  figures  are  relatively  high,  as  the  following  tabu- 
lation of  the  38  Hamburg  cases  will  show : 

Sixteen  were  between  the  ages  of  fifteen  and  twenty  years ;  15  between 
twenty-one  and  twenty-five  ;  10,  twenty-six  and  thirty  ;  4,  thirty-one  and 
thirty-five ;  3,  thirty -six  and  forty. 

Brief  reference  may  be  made  here  to  infection  of  the  fetus  with  the 
typhoid-bacillus.  Lynch, ^  who  has  reported  1  case,  from  the  heart's 
blood,  spleen,  and  kidney  of  which  the  typhoid-bacillus  was  isolated, 
and  also  1  case  with  entirely  negative  findings,  has  carefully  reviewed 
the  literature  and  collected  16  undoubted  cases  in  which  the  typhoid- 
bacillus  was  isolated  from  the  organs  of  the  fetus.  In  none  of  these 
cases  were  intestinal  lesions  found.  Among  the  earlier  cases  may  be 
mentioned  those  of  Eberth,^  Hildebrand,^  and  Ernst.*  He  has  also  col- 
lected 14  cases  in  which  very  careful  examinations  were  made  with  entirely 
negative  results.  From  the  existing  evidence  it  is  probable  that  infec- 
tion of  the  fetus  is  not  the  usual  sequel  of  typhoid  fever  in  the  mother, 
but  that  favoring  conditions  must  be  additionally  operative.  Thus,  in 
the  case  of  Ernst  the  mother  had  fallen  during  pregnancy,  and  it  can 
readily  be  conceived  that  in  consequence  of  the  traumatic  laceration  the 
placenta  was  rendered  permeable  to  the  bacilli.  Probably  the  most 
favoring  factor  is  to  be  found  in  the  hemorrhagic  infarcts  of  the  placenta, 
which  have  been  usually  noted  in  the  cases  with  positive  findings.  In 
Lynch's  positive  case  there  were  found  numerous  microscopic  hemor- 
rhagic infarcts,  while  in  the  negative  case  none  were  found. 

^  Johns  Hopkins  Hosp.  Bull.,  vol.  xii.  '^  Fortschr.  d.  Med. 

3  Ibid.,  1889,  Bd.  vii.  *  Ziegler's  Beitrage,  Bd.  viii.,  S.  188. 


(j2  TYPHOID  FEVER. 

Constitution  and  Social  Conditions. — With  regard  to  con- 
stitution, all  observers  aj^ree  that  tyjihoul  iexcr  is  one  of  those  diseases 
that  oeeiir  with  s])eeial  readiness  and  fre([uency  in  well-nonrished  young 
persons  situated  amid  l"a\(>ral)le  hygienie  siirroundiugs.  In  this  respect 
typhoid  fever  stjuids  in  contrast  witli  tyi)luis  fever  and  rela])sing  fever. 
AMiile  in  large  epidemics  of  the  two  latter  diseases  the  poorer  classes  in 
the  community,  especially  those  laboring  under  physical  distress  and 
generally  impaired  nutrition,  are  attacked,  ty})hoid  fever  demands  its 
sacrifices  alike  from  poor  and  rich,  from  high  and  low.  Certain 
transitory  mental  and  physical  conditions  appear  to  increase  the  pre- 
disposition, such  as  profound  emotional  disturbances,  grief,  care,  and 
excessive  physical  and  mental  activity.  A^"hether  these  influences 
operate  by  lowering  the  resistance  to  the  invasion  of  the  poison  or 
by  favoring  directly  the  reception  and  development  in  the  organs  of 
the  body,  is  as  yet  shrouded  in  doubt. 

The  mode  of  living",  which  plays  so  important  a  part  with  relation 
to  the  development  of  typhus  fever,  has  by  no  means  the  influence  upon 
the  development  of  typhoid  fever  that  was  formerly  attributed  to  it. 
While  crowding  in  small  rooms,  deficiency  of  air,  light,  and  ventilation 
increase  directly  the  capability  of  infection  and  dissemination  in  the  case 
of  typhus  fever,  these  influences  appear  to  be  operative  only  conditionally 
in  typhoid  fever.  In  connection  with  the  latter,  it  is  to  be  noted  that 
defective  household-conditions  are  usually  associated  also  with  imperfect 
drainage  and  provisions  for  cleansing,  factors  that  favor  the  accidental 
transference  of  the  poison  to  articles  of  food,  to  beverages,  and  to 
household-utensils.  That  typhoid  fever,  when  once  developed,  may  be 
materially  and  unfavorably  influenced  m  its  course  by  improper  sur- 
roundings, as  well  as  by  defects  in  constitution  and  improjier  mode 
of  life,  is  a  matter  of  daily  observation.  Similar  statements  may  be 
made  in  general  with  regard  to  social  position  and  occupation.  In 
this  respect  also  a  certain  contrast  to  other  infectious  diseases  is  to.  be 
emphasized. 

Ty})hoid  fever  is  not  conflned  to  poverty  and  misery  and  the  corre- 
s])onding  physical  conditions.  In  densely  populated  cities — and  these 
constitute  the  best  field  for  observation  in  this  connection — typhus  fever 
and  relapsing  fever  invade  the  homes  of  the  poor,  asylums  and  penal 
institutions,  workhouses  and  jails,  and  avoid  the  dwellings  of  the  rich  ; 
while  typhoid  fever  fiiils  to  recognize  these  limitations,  and  occurs  as 
frequently,  if  not  more  frequently,  among  the  better  classes  of  society  up 
to  the  highest  circles.  The  "misere  physiologique  "  affords  protection, 
instead,   against    the   disease.     The   special    relations   of   occupation   to 


ETIOLOGY.  63 

typhoid  fever  are  to  be  considered  from  this  standpoint.  Among  the 
working-classes  the  vigorous,  young  individuals  living  under  better 
conditions  and  engaged  in  more  healtliful  pursuits  are  witli  preference 
attacked.  A  special  predisposition  is  conferred  only  by  those  occupations 
that  necessitate  direct  exposure  to  the  invasion  of  the  typhoid  virus. 
In  this  class  belong  especially  those  employed  about  and  upon  the  water, 
as  laborers  in  harbors  and  seamen,  as  well  as  all  whose  occupation  brings 
them  in  contact  with  })atients  and  their  dejections,  namely,  physicians, 
nurses,  laundresses,  disinfectors,  and  workmen  on  canals  and  in  sewers. 
In  addition,  such  occupations  and  conditions  deserve  especial  mention 
that  necessitate  intimate  association  of  individuals  physically  predisposed 
in  marked  degree,  as,  for  instance,  internes  in  hospitals,  pupils  in  schools, 
soldiers  in  barracks,  etc. 

The  question  of  hospital-infection,  previously  referred  to,  is 
worthy  of  more  detailed  consideration.  Its  frequency  is  extreme  at 
different  times  and  in  different  institutions.  The  modes  of  conveyance 
from  typhoid  patients  to  other  patients  or  to  healthy  individuals 
can  in  general  be  only  the  same  as  those  under  other  conditions. 
Unfortunate  accidents,  as  a  result  of  which  the  poison  given  off  from  the 
patient,  and  contained  especially  in  the  dejections,  gains  access  directly 
or  indirectly  to  the  mouth  and  the  digestive  tract  from  the  hands  and 
the  clothing  of  the  nurses,  or  from  infected  articles,  household-utensils,  or 
from  articles  of  food  and  drink,  play  the  most  important  role  in  this  con- 
nection. The  frequency  with  which  cases  of  typhoid  fever  originate  in  a 
hospital  can  therefore  be  taken  as  an  index  of  its  hygienic  arrangements 
and  the  organization  of  the  medical  and  nursing  service.  To  what  extent 
especial  severity  of  the  epidemic  or  especial  personal  susceptibility  is 
operative  in  this  connection  is  not  yet  clear,  but  they  are  not  to  be 
wholly  ignored. 

At  times  a  hospital-epidemic  that  results  from  the  mistake  of  a  single 
inexperienced  or  careless  assistant  may  upset  the  best  hygienic  regulations. 
We  have  recently  had  such  an  unfortunate  experience  in  Leipsic  in  this 
connection.  In  Hamburg,  where  the  hygienic  conditions  of  the  hospital  are 
most  admirable,  I  observed  in  the  year  1887,  the  year  of  the  most  severe 
epidemic,  only  21  cases  among  the  inmates  of  the  hospital — about  0.57 
per  cent.  Among  these  there  were  only  11  who  had  previously  been 
patients  in  the  hospital,  thus  about  0.28  per  cent.  Among  these  11  only 
3  had  occupied  the  same  ward  as  other  typhoid  patients,  while  the  remain- 
der had  acquired  the  disease  in  the  surgical  clinic  and  the  skin-clinic,  proba- 
bly through  the  intei-mediation  of  some  third  person.  Murchison's  experi- 
ence in  the  London  Fever  Hospital  was  also  quite  favorable,  as  among 
10,048  cases  of  typhoid  fever,  hut  2  were  of  hospital  origin.  The  experi- 
ences of  other  hospitals  have  been  somewhat  less  favorable.     In  the  Jacobs- 


64  TYPHOID  FEVER. 

spital  of  Leipsic  35  eases — 2.15  per  ceut. — of  nosocomial  typhoid  fever 
occurred  iu  the  course  of  fourteen  years.  Here  the  nurses  and  the  assist- 
ants, among  whom  28  eases  occurred,  were  phicetl  uniler  far  more  unfavor- 
able conditions  than  those  under  their  care.  Liebermeister  had  an  almost 
similar  experience,  observing  among  1900  cases  (during  the  years  from 
1865  to  1871)  45 — 2.4  per  cent.  The  experiences  of  Alexander  at  the 
Breslau  Hospital  were  less  favorable,  14  cases — 8.6  per  cent. — of  noso- 
comial origin  being  observed  among  393  patients.  The  experiences  at  Kiel 
were  the  most  unfavorable  (Goth'),  namely,  5.5  per  cent. 

In  the  Johns  Hopkins  Hospital,  Baltimore,  20  cases  of  typhoid  fever 
have  originated  in  the  hospital  since  its  o})eniug,  eleven  years  ago.  During 
this  time,  1100  cases  of  typhoid  fever  have  been  treated,  making  the  per- 
centage of  eases  of  hosj)ital  origin  1.81.  Of  those  infected,  8  were  nurses,  3 
physicians,  7  patients,  1  orderly,  and  1  maid.  Four  of  the  7  eases  among 
patients  occurred  in  one  ward  at  the  same  time.  Three  cases  of  typhoid 
fever  have  occurred  among  doctors  and  students  working  in  the  pathologic 
laboratory  of  this  hospital.  In  one  case,  that  of  a  student,  a  })ossibIe  source 
of  infection  could  be  traced  to  w'ashing  test-tubes  containing  cultures  of 
typhoid-bacilli  without  previously  sterilizing  them. 

Ou  the  whole,  my  experience  shows  that  in  well-conducted  hospitals 
isolation  of  typhoid  patients  is  not  necessary.  Only  under  special 
contUtions,  particularly  when  the  administrative  arrangements  are 
insufficient,  and  the  relations  between  the  administrative  and  the 
medical  officers  is  uncertain,  would  permanent,  or  at  least  temporar}', 
segregation  of  typhoid  patients  from  the  remainder  be  required. 

The  action  of  cold  and  the  transitory  bodily  disturbances  referable 
to  it  are  frequently  mentioned  as  factors  favoring  the  development  of 
typhoid  fever.  For  this  there  is,  however,  no  positive  evidence,  and  not 
even  trustworthy  support  based  upon  experience,  which,  as  will  be  seen, 
may  be  invoked  in  favor  of  other  contributing  conditions.  I  believe 
that  the  growth  of  the  belief  that  cold  favors  the  development  of 
typhoid  fever  is  the  result  of  confusion  with  conditions  that  are  them- 
selves a  part  of  the  disease.  I  may  mention  in  this  connection  the 
sense  of  cold  and  the  sweating  of  the  period  of  incubation,  as  Avell  as 
the  initial  chilliness.  Whether  the  influence  of  cold  in  those  already 
infected — that  is,  in  the  period  of  incubation  of  typhoid  fever — acceler- 
ates the  outbreak  of  the  disease,  as  appears  demonstrated  for  a  number 
of  other  infectious  diseases,  as,  for  instance,  fibrinous  pneumonia,  is 
yet  doubtful.  The  cases  seem  to  have  a  positive  significance  in  Avhich 
the  first  symptoms  of  typhoid  fever  appeared  after  a  cold  bath,  or  a 
fall  in  water,  or  sleeping  in  the  0])en  air,  etc.  These  cases  are,  how- 
ever, by  no  means  conclusive.  It  must  always  be  borne  in  mind,  for 
instance,  that  inunersion  in  infectious  water  may  be  followed  directly  by 
entrance  of  the  poison  into    the    body  and  rapid  development  of  the 

'  Loc.  cit. 


ETIOLOaY.  65 

disease.  In  Hamburg  I  have  more  than  once  ()bs(!rved  typhoid  result 
from  bathing  in  the  infected  water  of  the  Elbe,  and  so  far  as  my 
influence  reached  I  have  warned  against  all   contact  with  this  water. 

Relations  between  Typhoid  Fever  and  Still  i^xisting  or 
Antecedent  Diseases. — In  the  first  place,  the  acute  infectious  dis- 
eases are  deserving  of  consideration  in  this  connection.  The  existence 
of  one  of  these,  particularly  at  the  febrile  joeriod  of  the  disease,  appears 
to  protect  with  considerable  certainty  against  infection  with  typhoid 
fever.  I  am  unable  to  record  an  observation,  either  clinical  or  anatomic, 
opposed  to  this  statement.  I  have  exceptionally  observed  typhoid  fever 
during  convalescence  from  an  acute  infectious  disease.  Nevertheless,  I 
have  gained  the  impression  that  the  patients  under  these  conditions  also 
are  immune  to  a  certain  degree.  At  any  rate,  they  appeared  to  me  the 
more  susceptible  the  further  removed  in  time  they  were  from  the  febrile 
stage  of  the  antecedent  disease. 

In  accordance  with  the  view  already  mentioned,  according  to  which 
well-nourished  and  robust  individuals  are  more  readily  attacked  than 
those  in  a  reduced  state,  it  is  probable  that  when  nosocomial  typhoid 
fever  occurs  shortly  after  convalescence  from  antecedent  infectious  dis- 
ease, the  attack  often  assumes  a  milder  or  less  profound  character.  In 
the  latter  connection  mention  may  be  made  especially  of  angina  simplex 
and  rheumatic  polyarthritis.  Extensive  observations  on  the  part  of 
others  in  this  connection  are  not  recorded.  These  would  be  very  valu- 
able, as  only  large  statistics  would  be  conclusive. 

It  has  been  asserted  by  some  observers — assuredly  not  correctly — 
that  epidemiologically  small-pox  and  scarlet  fever  exhibit  a  certain 
antagonism  to  typhoid  fever.  This  has  been  used  as  a  weapon  by  the 
opponents  of  vaccination  (Gressot,^  Carnot^),  who  advanced  the  view, 
based  upon  superficial  observation,  that  the  repression  of  small-pox 
favors  the  development  of  typhoid  fever.  Also  the  opinion  now  and 
again  exj)ressed  that  malaria  and  typhoid  fever  are  antagonistic  to  each 
other  has  not  been  confirmed.  I  have  myself  observed  malaria  and 
typhoid  fever  m  the  same  place  upon  the  Ehine. 

Three  cases  of  mixed  infection  with  the  malarial  parasites  and  B.  typho- 
sus have  occurred  in  the  Johns  Hopkins  Hospital  amoug  about  1100  cases 
of  typhoid  fever  treated,  Lyon,^  who  has  reported  one  of  these  cases,  has 
collected  29  undoubted  cases,  besides  numerous  other  cases  in  which  the 
evidence  was  not  so  conclusive.  He  concludes  that  in  tropical  countries, 
where  malarial  fever  is  endemic  and  typhoid  fever  prevalent,  it  seems 
entirely  probable  that  cases  of  combined  infection  are  common. 

'  Edinb.  Med.  Jour.,  July,  1855.  ^  Jiev.  de  med.,  1856. 

^  Johns  Hopkins  Hosp.  Rep.,  vol.  viii. 
5 


66  TYPHOID   FEVER. 

Among:  the  clironic  ini'ot'tious  diseases  pulmonary  tuberculosis  has 
often  been  spoken  of  in  this  eonneetion,  tubereulous  patients  being  on 
the  M'hole  looked  upon  as  proteeted.  Also,  aeeording;  to  my  experience, 
indivitiuals  in  the  middle  and  especially  in  the  advanced  stage  of"  pul- 
monary tuberculosis  are  (piite  rarely  attacketl  by  typhoid  fever,  and  this 
is  the  more  noteworthy  because  such  patients  generally  remain  in  the 
hospitals  for  a  long  time,  and  therefore  are  with  relative  frequency 
brought  into  contact  with  typhoid  ])atients.  It  is  my  impression,  how- 
ever, that  in  this  connection  no  s})ccific  condition  of  the  body  is  to 
be  taken  into  consideration,  but  that  the  emaciation  of  the  patient  is 
the  important  factor,  for  patients  suffering  from  other  chronic  affec- 
tions of  various  kinds,  from  malignant  neoplasms,  chronic  constitutional 
diseases,  and  especially  diabetes,  are  scarcely  ever  attacked  ^\\i\\  typhoid 
fever,  in  spite  of  frequent  exposure  to  infection.  In  harmony  with  this 
view  is  the  fact  that  well-nourished,  afebrile  tuberculous  patients  or 
individuals  with  latent  tuberculosis  are  by  no  means  imnunie  to  typhoid 
fever.  Every  experienced  chnician  will  have  had  some  gloomy  expe- 
riences with  reference  to  the  development  of  tuberculosis  or  the  rapid 
progress  of  previously  recognized  circumscribed  infiltration  of  the  lungs 
during  the  course  of  typhoid  fever.  Also  the  other  chronic  diseases 
of  the  lungs,  emphysenui  and  chronic  bronchitis,  as  well  as  bronchi- 
ectasis, appear  to  behave,  ^yith  relation  to  the  liability  of  infection, 
in  accordance  with  the  age  and  general  physical  condition  of  the 
patient. 

Chronic  diseases  of  the  nervous  system,  in  so  far  as  they  occur  in 
individuals  within  the  predisposed  period  of  life,  and,  as  so  often  hap- 
pens, for  a  long  time  do  not  injure  the  constitution,  afford  no  immunity 
to  typhoid  fever.  The  statement  that  dietetic  error  with  secondary 
gastro-intestinal  catarrh  gives  rise  to  tyi)hoid  fever  is  no  longer  a 
matter  for  discussion  at  the  present  day.  The  view,  conceivable  from 
an  earlier  etiologic  standpoint,  is  based  upon  an  incorrect  interpretation  of 
various  observations.  Thus,  it  is  certainly  not  uncommon  for  the  first 
symptoms  of  typhoid  fever  to  be  confounded  with  those  of  simple 
gastro-intestinal  catarrh.  The  danger  is  especially  great  Avith  reference 
to  cases  of  walking  typhoid  fever,  whose  true  nature  is  often  only  first 
recognized  when  the  patient  is  compelled  to  go  to  bed  after  a  relapse 
attended  with  high  fever.  On  the  other  hand,  it  can  be  readily  under- 
stood that  dietetic  errors  with  their  consequences  may  favor  the  lodge- 
ment and  the  develo})ment  of  the  contagium,  and  it  is  not  improbable 
that  it  may  accelerate  the  outbreak  of  the  disease  in  individuals  already 
infected.     Support  for  this  view  is  afforded  by  the  observation    that 


ETIOLOGY.  67 

the  occurrence  of   relapses    and    recrudescences    is   not    rarely   dirc(;tly 
related  to  dietetic  errors. 

The  predisposing  influence  of  acute  and  chronic  diseases  of  the  stomach 
is  probably  dependent  u[)on  the  alteration  in  hydrochh)ri(;  acid  secretion  to 
which  they  give  rise.  According  to  observations  made  in  other  infectious 
diseases  invading  the  body  through  the  digestive  tract,  this  was  to  have  been 
anticipated.  Although,  as  has  been  mentioned,  the  typlioid-bacilli  are  relatively 
more  i-esistant  than  other  pathogenic  micro-organisms  to  the  action  of  the 
gastric  juice,  it  cannot  be  doubted  that  transitory  or  protracted  absence  or 
considerable  diminution  in  the  free  hydrochloric  acid  materially  favors  their 
safe  entrance  into  the  intestinal  tract.  Theoretically,  it  may,  on  the  other 
hand,  be  assumed,  although  practical  evidence  in  favor  of  this  view  has  not 
yet  been  presented,  that  gastric  disorders  attended  with  hyperacidity  afford 
relative  protection  against  the  typhoid-bacillus.  Certain  observations  that 
Bouchard  and  his  pupil  Le  Gendre  ^  emphasize  may  be  in  accord  with  the 
changes  in  the  qualities  of  the  gastric  juice  and  in  the  character  of  the 
gastric  contents.  They  believe  the  statement  justified  (Le  Gendre)  that 
about  60  per  cent,  of  all  typhoid  patients  have  previously  suffered  from 
dilatation  of  the  stomach.  As  patients  with  chronic  dilatation  of  the  stom- 
ach generally  exhibit  marked  alterations  in  the  gastric  juice,  particularly 
absence  or  deficiency  in  free  hydrochloric  acid,  an  explanation  for  the  state- 
ments of  those  observers  may  be  found  in  this  circumstance.  I  feel  com- 
pelled, however,  on  the  basis  of  my  own  clinical  and  anatomic  observations, 
to  deny  these  statements  emphatically.  These  have  shown  that  the  coinci- 
dence of  dilatation  of  the  stomach  and  typhoid  fever  is  by  no  means  espe- 
cially common.  I  am  unable  to  confirm  also  the  further  statement  of 
Bouchard  and  Le  Gendre  that  typhoid  fever,  on  the  other  hand,  not  rarely 
causes  dilatation  of  the  stomach  in  previously  healthy  persons. 

Repeated  Attack  ;  Imtnunity. — Whether  there  are  individuals 
possessing  congenital  immunity  to  infection  with  the  typhoid  poison  has 
not  yet  been  determined.  At  all  events,  this  is  extremely  rare,  perhaps 
even  less  frequent  than  is  known  to  be  the  case  for  other  infectious  dis- 
eases, particularly  the  acute  exanthemata.  On  the  other  hand,  it  is  a 
firmly  established  observation  that  recovery  from  one  attack  of  typhoid 
fever  confers  relative  protection  from  subseqnent  attacks  of  the  disease. 
Even  older  observers  (Bretonneau,  Chomel,  Louis,  Budd,  Jenner,  Mur- 
chison,  down  to  Griessinger)  are  in  agreement  as  to  this  fact ;  but  they  as 
well  as  all  more  recent  observers  properly  emphasize  the  fact  that  the 
immunity  acquired  by  recovery  from  an  attack  of  typhoid  fever  is  not 
so  protracted  as  has  been  shown  to  be  the  case  for  most  acute  exanthe- 
mata, including  typhus  fever.  It  is  certain  that  in  many  persons  it 
does  not  extend  throughout  the  whole  of  life.  Whether  a  severe  attack 
of  typhoid  fever  confers  more  marked  or  more  protracted  protection 
than  mild  cases  is  unknown.  This  would  not  be  in  accord  with  the 
experiences  in  other  infectious  diseases,  and  also  with  some  recent  experi- 
^  Dilatation  de  I'estomac  etfievre  typhdide,  etc.,  These,  Paris,  1886. 


68  TYPHOID  FEVER. 

mental  observations.  Aceordino-  to  my  own  experience,  two  attacks  of 
typhoid  fever  iu  the  same  person  are  by  no  means  rare.  There  are 
even  individnals  who  have  had  three  or  fonr  attacks  during  their  lives. 
Such  au  occurrence  naturally  is  a  rare  exception. 

Among  1888  patients  examined  with  ,<rreat  care  iu  regard  to  this  point 
during  the  epidemic  iu  Handiurg  iu  1<S<S7,  there  were  54  iu  their  second 
attack — 2.4  per  ceut.  Oue  patient  was  witli  certainty  in  his  third  attack. 
Among  these  54  patients  there  were  15  who,  during  tlie  first  attack  of 
typhoid  fever,  also  had  heeu  treated  iu  the  Geueral  Hospital,  and  the 
diagnosis  could  be  verified  from  the  pi'eserved  histories  aud  temperature- 
charts.  In  the  remaining  39  the  statement  was  accepted  only  when  the 
evidence  was  most  positive. 

Typhoid  fever  presents  a  noteworthy  diiference  from  the  acute  exan- 
themata in  the  fact  that  complete  unmunity  docs  not  exist,  as  in  the  latter, 
during  the  first  period  after  the  disease,  and  that  progressive  diminution 
does  not  subsequently  take  place  in  proportion  to  the  time  elapsing 
after  the  first  attack.  On  the  contrary,  T  have  observed  individuals 
attacked  for  a  second  time  before  the  end  of  the  first  year  or  Avithin 
a  few  years  after  recovery  from  typhoid  fever. 

I  have  reliable  records  upon  this  point  iu  46  cases  iu  which  a  second 
attack  occurred.  These  show  that  iu  30  the  second  attack  of  typhoid  fever 
occurred  before  the  lapse  of  ten  years.  In  the  15  cases  in  which  l)oth 
attacks  were  treated  iu  the  General  Hospital,  the  intervals  were  as  follows : 
nine  mouths  in  2  cases  ;  one  year  in  4  ;  two  yeai-s  in  2  ;  three  years  iu  1  ; 
four  years  in  3  ;  five  yeai's  in  2  ;  thirty-nine  years  iu  1. 

Iu  the  case  under  observation  in  which  3  attacks  occurred,  the  first  2 
likewise  had  followed  iu  quick  succession.  The  patieut  was  a  man,  forty- 
seven  years  old,  who  had  lived  in  Hamburg  from  the  year  1877,  aud  was 
first  seized  with  a  severe  attack  of  typhoid  fever  iu  the  winter  of  1877-78, 
and  was  attacked  for  the  second  time  in  the  year  1879.  The  third  aud  by 
far  the  mildest  of  the  three  attacks  occurred  iu  the  year  1887.  All  of  the 
attacks  were  treated  in  the  General  Hospital.  Probably  this  patieut  had 
even  had  an  additional  attack  of  typhoid  fever  iu  the  year  1856  ;  at  least 
he  stated  that  he  was  at  that  time  under  treatment  in  Altona  for  three  weeks 
for  ''gastric  fever." 

Observations  of  the  repeated  occurrence  of  typhoid  fever  iu  the  same 
individual  have  been  reported  from  various  sources.  The  figures  agree 
in  general  with  my  own.  Thus,  Goth  in  Kiel  has  noted  two  attacks  in 
2  per  cent,  of  his  cases,  Beetz^  in  1.8  per  cent.,  and  Freundlich^  in  2.2 
per  cent.  A  high  percentage  is  noted  b^^  Eichhorst,^  who  has  given 
especially  careful  and  exhaustive  consideration  to  the  subject.  Among 
666  cases  of  typhoid  fever,  he  found  28 — 4.2  per  cent. — in  which  two 
attacks  had  occurred.     Also,  he  observed  cases  in  which  there  had  been 

^  Deutsch.  Arch.f.  klin.  Med.,  Bd.  xvi.  u.  xvii.  ^  Ibid.,  Bd.  xxxiii. 

^  Virchow^s  Archiv,  Bd.  cxi. 


ETIOLOGY.  69 

three  and  even  four  attacks,  as  also  Quincke '  and  Goth  ^  1  case  each 
in  which  there  had  been  three  attaclvs. 

With  regard  to  the  intensity  of  tlie  second  and,  in  general,  c)f  any 
subsequent  attack  of  typhoid  fever,  this  need  not,  according  to  my 
experience,  be  less  than  that  of  the  first  attack.  On  the  contrary,  there 
have  been  among  my  cases  some  in  which  the  first  attack  was  mild, 
while  the  second  was  so  severe  as  to  terminate  fatally.  This  is  in 
accord,  on  the  whole,  with  the  every-day  experience  that  relapses  and 
recrudescences  may  be  more  severe  and  more  protracted  than  the  pri- 
mary attack.  In  this  respect  also  there  is  a  certain  'contrast  with  the 
behavior  of  the  acute  exanthemata,  as  a  type  of  which  variola  may 
again  be  mentioned.  It  is  loiown  that  second  attacks  of  this  disease 
are  almost  invariably  much  less  severe  than  the  first  attack. 

All  of  the  foregoing  facts  have  been  learned  from  and  are  based 
upon  empiric  observation.  With  increasing  knowledge  of  the  vital 
activities  of  the  pathogenic  micro-organisms,  a  better  insight  into  the 
nature  of  immunity  has  been  gradually  obtamed  both  theoretically  and 
experimentally.  Although  certain  definite  and  in  some  respects  con- 
clusive results  have  been  reached  with  regard  to  a  number  of  acute 
infectious  diseases  (tetanus,  diphtheria),  and  which  have  even  borne 
brilliant  fruit  from  a  practical  point  of  view,  this  aspect  of  the  question 
with  regard  to  typhoid  fever  is  still  unsettled.  It  may  be  considered  as 
demonstrated  in  this  connection  (R.  Stern  ^)  that  the  blood-serum  of 
convalescents  from  typhoid  fever  continues  to  possess  for  some  time  the 
property  of  protecting  experimental  animals,  especially  mice,  from  the 
deleterious  effects  of  typhoid  cultures.  It  has  also  been  possible  to 
immunize  animals  to  the  action  of  the  typhoid-bacillus  by  means  of 
filtered  or  unfiltered  typhoid  bouillon -cultures ;  and  it  has  also  been 
found  that  the  blood-serum  of  such  immunized  animals  is  in  turn 
capable  of  immunizing  other  predisposed  animals. 

By  means  of  an  elaborate  series  of  experiments,  Pfeiffer  and  Kolle* 
have  also  shown  that  the  blood-serum  of  typhoid  convalescents  contains 
substances  which,  when  the  serum  in  very  small  amounts,  together  with 
a  culture  of  the  typhoid-bacillus,  is  injected  into  the  abdominal  cavity 
of  a  guinea-pig,  have  marked  bactericidal  properties.  These  substances 
are  the  specific  "  anti-bodies,"  corresponding  to  those  described  by 
Pfeiffer  in  immune  cholera-serum.  They^  later  showed  that  similar 
"  anti-bodies  "  could  be  produced  in  the  serum  of  normal  men  by  inject- 

^  Deutsch.  Arch.  f.  Mm.  Med.,  Bd.  xxxix.  ^  Inaug.  Diss.,  Kiel,  1886. 

^  Deutsch.  med.   Woch.,  1892,  No.  37.  *  Zeit.  f.  Hyg.,  Bd.  xxi. 

5  Deutsch.  med.   Woch.,  Nov.  12,  1896. 


10  TYPHOID  FEVER. 

ing  them  with  dead  typhoi(l-l)acilli  of  liiuh  virulence.  A  certain  amonut 
of  rcactit)n  was  caiiscil  by  the  injection,  i'ollowint;-  which  the  serum 
showed  niarketl  bactericidal  and  a<2:i;lutiiiati\e  ja'operties. 

Similar  results  were  obtained  by  Wright  and  8eniple,'  under  whose 
direction  this  method  of  preventive  inoculation  has  been  ])ractieally 
em})loyed  to  a  very  cousidemble  extent  in  India  and  in  the  South 
African  War.  The  results  so  far  obtained  ap])ear  verv  })romising.  xVl! 
of  these  results  have  shown  that  immunity  in  typhoid  is  like  that  in 
cholera — it  is  due  to  the  production  of  l)actericidal  substances  in  the 
blood,  and  not  to  the  })roduction  of  antitoxins.  At  present  there  is  no 
evidence  that  antitoxic  substances  are  ever  formed. 

EXTERNAL,  NOT  INDIVIDUAL,  INFLUENCES. 

I/Ocal  Conditions;  Geographic. — At  a  time  when  a  spon- 
taneous development  of  typhoid  fever  was  still  believed  in,  or,  at  least, 
when  the  opinion  was  held  that  the  preservation,  maturation,  and 
dissemmation  of  the  specific  contagium  were  dependent  upon  the  earth 
and  air,  much  greater  and  even  decisive  significance  was  attached 
to  the  local  conditions.  At  that  time  it  ^^as  believed  that  the  ])oison 
was  constantly  present,  undergoing  a  sort  of  storing  up  and  constant 
reproduction  in  certam  cities  and  entire  regions.  From  this  point  of 
vaeAv,  suspicious  houses,  streets,  localities,  and  cities  were  spoken  of.  It 
was  believed  that  here  only  general  influences  of  season,  temperature, 
water-level,  especially  of  the  ground-water,  often  in  association  with 
contemporaneous  excavations  of  the  soil  and  the  construction  of  sewers, 
were  necessar\'  in  order  to  render  the  stored-up  poison  active  throughout 
the  community.  At  the  present  day  it  is  known,  on  the  other  hand,  that 
the  so-called  local  predisposition  is  scarcely  dependent  upon  the  constant 
preservation  and  reproduction  of  the  poison  in  certain  places,  but  upon 
the  flict  that  certain  conditions,  temporarily  or  permanently  peculiar 
to  such  places,  are  capable  of  rendering  active  temporarily,  and  of 
disseminating,  the  contagium  arising  locally  from  the  typhoid  patient 
or  imported  from  without.  To  be  taken  into  consideration  especially 
are  conditions  that  facilitate  the  dissemination  of  the  poison  and  its 
conveyance  to  the  human  body  through  the  digestive  tract.  It  is 
obvious  from  previous  considerations  that  here  again  the  condition 
of  the  water-supply  of  a  ])lace  is  of  utmost  importance.  In  this 
matter  the  relations  between  the  subsoil  and  the  water-su])ply  are  natu- 
rally of  importance,  and  frf»m  this  point  of  view  eveiy  physician  should 

1  Brii.  Med.  Jour.,  .Jan.  30,  1897. 


ETIOLOGY.  71 

make  himself  familiar  with  the  conditions  of  the  soil  and  the  groiuid- 
water  of  a  place,  especially  in  its  relations  to  the  wells  and  other  sources 
of  water-supply. 

There  have  heen  made  in  this  connection  numerous  valuable  investi- 
gations beariug  upon  the  differences  in  the  permeability  of  the  soil  and 
upon  the  mode  and  the  direction  in  which  the  specifically  contaminated 
ground-water  is  conveyed.  Not  less  numerous  studies  refer  to  the  occurrence 
of  the  disease  in  places  where  the  water  used  for  drinking  and  for  house- 
hold purposes  was  derived  not  from  wells,  but  from  a  distance  through  con- 
duits, springs,  and  other  waterways.  Under  such  conditions  the  danger  of 
contamination  of  the  water  with  typhoid-bacilli  during  transmission  is  espe- 
cially to  be  considered  and  investigated.  It  should  particularly  be  estab- 
lished whether  the  water-supply  is  conveyed  through  conduits  that  are 
everywhere  closed  and  protected  in  greater  or  lesser  degree  against  the 
entrance  of  foreign  bodies,  or  is  derived  from  open  water-courses.  In  the 
latter  event  the  sanitary  condition  of  the  people  dwelling  in  proximity  to 
the  stream,  and  the  character  of  their  industries,  play  a  role  that  can  he 
accurately  estimated. 

In  addition  to  the  local  peculiarities  just  described,  a  number  of 
general  conditions  are  of  great  importance,  especially  the  density  and 
the  character  of  the  population,  the  food-supply,  as  well  as  other  vital 
and  special  sanitary  conditions.  Also,  the  amount  and  the  character 
of  the  commerce  are  of  great  importance  with  regard  to  the  possibility^ 
of  dissemination  of  the  typhoid  poison.  In  a  word,  there  must  be  taken 
into  consideration  a  large  number  of  varied  conditions,  in  part  well 
known,  in  part  still  but  little  investigated  and  with  difficulty  estimated 
according  to  their  importance,  but  which  in  all  possible  local  and  tem- 
poral combinations  exert  a  marked  influence.  At  the  present  day  the 
etiology  of  typhoid  fever  in  certam  places  and  localities  cannot  be  as 
easily  and  systematically  laid  down  as  appeared  possible  at  the  time 
when  the  ground-water-theory  flourished. 

How  little  bearmg  locality  itself  and  its  general  atmospheric  and 
climatic  conditions  have  upon  the  etiology  of  typhoid  fever  is  demon- 
strated by  the  general  distribution  of  the  disease  over  the  entire  world, 
and  therefore  incluclmg  localities  that  exhibit  the  most  violent  contrast 
with  regard  to  the  conditions  named  :  typhoid  fever  is  present  at  a  con- 
siderable elevation  and  at  sea-level,  m  northern  regions  and  in  the 
tropics.  It  occurs  wherever  the  reproduction  and  dissemination  of  the 
imported  specific  contagium  are  not  prevented  by  local  conditions ;  and 
although  these  are  most  variable  in  degree,  with  the  aid  of  unfavor- 
able accidents,  they  appear  nowhere  capable  of  preventing  entirely  the 
development  and  dissemination  of  the  disease.  Thus,  it  is  always  an 
unfortimate  occurrence  for  the  adherents  of  the  localization-theory  when 
the  disease  is  suddenly  imported  into  a  place  previously  immune,  and 


72  TYPHOID  FEVER. 

when  couditioDs  favoring  its  dissemination.,  and  previously,  of  course, 
not  taken   into  consideration,   make  themsolvcs  actively  manifest. 

AVith  regard  to  the  special  geographic  distribution  of  typhoid  fever, 
the  works  of  JNIurchison,  Hirsch,'  and  of  Griessinger,  who  had  veiy  ^ide 
experience,  gi\e  the  best  information.  Ty})hoid  fever  prevails  through- 
out ]\Iiddle,  Southern,  and  Northern  Europe.  The  disease  is  encountered 
in  Spain,  in  Turkey,  in  Italy  and  Greece,  in  Northern  Russia,  and  in 
the  Scandinavian  cities.  In  England  and  in  a  number  of  countries  of 
Eastern  Europe  it  occurs  endemically  in  tiie  same  places  as  ty])hus  fever, 
a  circumstance  that,  especially  m  England,  prevented  for  a  long  time 
the  clinical  differentiation  of  the  two  diseases.  Numerous  reports  have 
been  made  from  North  America,  Central  America  and  South  America, 
from  jSIexico, '  Brazil  and  Peru,  from  Asia,  especially  from  India  and 
from  the  large  islands  of  Java,  Sumatra,  Borneo,  etc.,  as  to  the  endemic 
occurrence  and  temporarily  increased  prevalence  of  typhoid  fever.  It 
has  been  observed  also  in  Africa  as  far  as  communication  has  been 
established,  particularly  upon  the  east  and  the  west  coast,  among  the 
natives  as  well  as  among  Europeans.  Griessinger  long  ago  proved,  in 
a  manner  that  must  forever  serve  as  a  model  for  similar  investigations, 
the  endemic  occurrence  of  typhoid  fever  in  Egypt. 

Apparently,  the  warm  and  tropical  countries  do  not  differ  greatly  from 
cold  regions  with  reference  to  the  occurrence  and  frequency  of  typhoid 
fever.  Epidemics  of  typhoid  fever  have  been  observed  even  upon 
high  mountams,  in  places  more  than  1000  meters  high.  The  epidemic 
upon  the  great  St.  Bernard  and  in  the  valleys  radiating  from  it,  also 
cited  by  Griessinger,  is  well  knoAvn.  At  that  time  one-third  of  all  of  the 
monks  m  the  monastery  at  that  place  were  attacked. 

Apart  from  the  ability  of  the  typhoid-bacillus  to  become  lodged  and 
develop  in  any  locality,  and  its  not  inconsiderable  tenacity,  the  wide 
distribution  of  the  disease  depends  further  upon  the  apparently  equal 
susceptibility  of  all  races  to  it.  In  this  regard  also  typhoid  fever 
exhibits  a  contrast  with  other  infectious  diseases,  since  to  these  there 
are  marked  variations  in  racial  susceptibility. 

It  should  be  mentioned  that  persons  who  have  recently  removed 
to  a  so-called  typhoid  locality  or  have  resided  in  such  a  place  but  for  a 
short  time  are,  as  numerous  observations  have  shown,  attacked  with 
especial  readiness.  Such  observations  have  been  made  in  Paris  and 
London  by  Louis,  Chomel,  Jenner,  and  Murchison.  The  physicians  of 
Vienna,  and  especially  those  of  Munich,  have  had  a  similar  experience. 
An  explanation  for  these  undoubted  facts  is  as  yet  wantmg.     Formerly, 

*  Hist,  geogr.  Path. 


ETIOLOGY 


73 


a  sort  of  "  acclimatization  "  was  off'haiul  coiisiclorcd  as  a  prophylactic 
against  the  disease.  As  unsii])i)orted  as  this  assumption  has  always 
been,  it  has  become  entirely  untenable  in  the  light  of  recent  knowledge. 
Various  conditions  must  be  taken  into  consideration  in  the  explanation. 
In  the  first  place,  the  new,  unusual  mode  of  life  for  newcomers,  often 
differing  greatly  from  the  previous  mode  of  life,  and  so  favoring 
the  digestive  diseases  predisposmg  to  typhoid  infection,  is  of  impor- 
tance. In  the  next  place,  it  must  be  borne  in  mind  that  the  new- 
comer is  in  greater  degree  exposed  to  the  danger  of  taking  up 
the  poison,  because,  unlike  the  natives,  he  has  not  been  taught  by 
experience  against  partaking  of  dangerous  things.  In  this  connection 
the  drinking-water  and  articles  of  food  eaten  in  the  uncooked  state  are 
to  be  mentioned — in  southern  countries,  for  instance,  raw  fruit,  oysters 
and  other  shell-fish.  Too  little  importance  should  not  be  attached  to  the 
circumstance  that  among  the  newcomers  there  will  be  many  with  a 
marked  personal  predisposition.  With  regard  to  transitory  residence  or 
increase  in  population  in  a  place,  healthy,  young,  and  adolescent  persons, 
travellers,  mechanics,  laborers,  servants,  etc.,  are  especially  concerned. 
"  Acclimatization-diseases  "  are  often  spoken  of,  particularly  diarrhea, 
by  which  newcomers  in  a  typhoid  place  are  attacked.  It  is  not  improb- 
able that  these  are  often  dependent  upon  typhoid  infection. 

Cases  of  Typhoid  Fever  received  into  Jacohsspital,  of  Leipsic,  from  1880  to 

1892. 


Year. 

1880. 

1881. 

1882. 

1883. 

1884. 

1885. 

1886. 

1887. 

1888. 

1889. 

1890. 

1891. 

1892. 

Total. 

Jan. 

9 

10 

12 

6 

12 

21 

9 

3 

2 

10 

10 

9 

9 

122 

Feb. 

V 

4 

8 

8 

17 

14 

7 

8 

3 

8 

3 

10 

3 

96 

March 

5 

8 

V2 

5 

13 

11 

4 

10 

1 

3 

8 

14 

5 

97 

April 

8 

8 

2 

10 

15 

10 

7 

2 

5 

9, 

7 

6 

8 

78 

May 

11 

8 

2 

4 

5 

11 

4 

1 

6 

5 

3 

6 

4 

71 

June 

5 

10 

3 

8 

2 

6 

3 

4 

19 

1 

5 

4 

9 

75 

July 

6 

17 

6 

21 

6 

10 

8 

12 

8 

22 

14 

10 

9 

136 

Aug. 

IB 

87 

10 

•16 

21 

16 

14 

18 

8 

46 

25 

15 

8 

252 

Sept. 

M 

^9 

18 

20 

19 

9 

16 

15 

4 

33 

26 

13 

16 

240 

Oct. 

17 

iil 

5 

11 

10 

5 

23 

16 

9 

30 

T8 

12 

193 

Nov. 

9 

21 

6 

18 

8 

4 

9 

7 

7 

23 

11 

10 

17 

150 

Dec. 

4 

4 

4 

4 

10 

3 

6 

7 

10 

11 

7 

7 

2 

88 

Season  and  Meteorologic  Conditions.— Typhoid  fever  ex- 
hibits a  constant  and  for  many  countries  a  uniform  relation  to  the  seasons. 
Upon  the  continent  of  Europe,  in  England,  and  m  countries  presenting 
similar  conditions,  as,  for  instance,  North  America  (Bartlett,  ^Yood, 
Flint),  there  prevails,  so  far  as  reports  go,  remarkable  unanimity  in  this 
regard.  Everywhere  the  increased  frequency  occurs  durmg  the  late 
summer  and  autumn  months.  In  especially  severe  and  widespread  epi- 
demics it  persists  or  increases  even  into   the  winter,  until  :N"ovember 


74 


TYPHOID  FEVER. 


and  December.  From  this  time  there  is  nhnost  always  a  slow  or  a  more 
rapid  decline.  The  period  of  least  ]irevalcnc'e  of  ty[)hoid  fever  is  every- 
where the  spring-  and  the  beginning  of  summer,  especially  the  mouths 
of  March,  April,  and  May. 

lu  Leipsic,  as  the  accoiupanviug  diagrammatic  representation  of  the 
cases  observed  in  the  Jacohssjntal  between  the  yeai'S  1880  and  1892  shows, 
the  months  in  whicli  the  largest  number  of  cases  oci-urred  were  invari- 
ahly  August,  Se})tember,  and  October.  Novenilier  also  exhibited  on  the 
average  high  ligures.  The  lowest  prevalence  in  Lei})sic  occurs  in  the  months 
of  April,  ]\Iay,  and  June.  In  July  the  increase,  however,  genei'ally  begins 
again,  aud  it  continues  uniuterruptetlly  to  its  acme  during  the  autumn 
months  (Fig.  4).  A  table  showing  the  nund^er  of  cases  received  during  the 
ditferent  months  and  years  is  added.  This  is  extremely  interesting  from 
the  general  uniformity  in  the  conditious  during  the  differeut  years.  Also 
in  Dresden,  according  to  the  observations  of  Fielder,'  extending  over 
eleven  years,  the  months  of  April  and  May  exhibit  the  least  frequency 
of  typhoid  fever,  while  August  and  Septendier  show  the  highest,  while  a 
greater  number  generally  occur  in  the  winter  months  than  in  June  and 
July.  A  striking  similarity  to  these  observations  is  exhibited  by  the  con- 
ditions in  London  as  descril)ed  by  IMurchisou  for  the  admissions  to  the  London 
Fever  Hospital  between  the  years  1848  and  1862.  1  have  prepared  a  dia- 
gram on  the  basis  of  his  statements  (Fig.   5).     In  its  details  the  London 


1 

is 

c 

■k 

■ 

=g 

1 

t 

1 

"1 

1 

11 

J 

250 

2W 

\ 

230 

\ 

220 

\ 

210 

I 

200 

- 

190 

180 

170 

160 

1 

150 

1^40 

130 

120 

\ 

no 

^ 

100 

^ 

1 

90 

\_ 

-V. 

\ 

80 

\ 

70 

K 

S' 

J 

60 

_ 

._ 

_ 

_ 

_ 

__ 

_ 

_ 

_l 

i 

M 

c 

s 

1. 

:i 

1 

"3 

i. 

1 

S 

1 

400 

380 

360 

/ 

\ 

3W 

/ 

320 

/ 

300 

/ 

280 

/ 

1 

260 

' 

\ 

2W 

\ 

2  20 

200 

180 

\ 

i 

160 

\ 

/ 

^W 

\ 

/ 

120 

V 

■y. 

J 

100 

\ 

y 

J 

80 

_j 

V 

_ 

„ 

1 

_ 

_^ 

J 

Fig.  4. 


Fig.  5. 


diagram  as  compared  with  that  of  Leipsic  exhibits  a  reduction  in  fre- 
quency during  the  winter  months  from  the  maximum  of  the  autumn  months, 
although  the  number  is  still  quite  large  during  the  month  of  December.  This 
relation  appears  to  exist  especially  in  those  places,  and  almost  everywhere 
in  those  years,  in  which  the  ascent  of  the  curve  begins  somewhat  later  and 
the  maximum  is  reached  correspondingly  later  (in  London  September 
and    October,   as   compared   with   August  in   Leipsicj.     The    epidemic   of 

'  Loc.  cit. 


ETIOLOGY. 


75 


1886-87  in  Hamburg  is  instructive  in  this  connection,  the  rapid  increase  in 
the  disease  occurring  during  the  months  of  September  and  October,  and 
accordingly  the  months  of  November,  December,  and  January  exhibiting 
the  maximum  prevalence  (Fig.  6). 


§ 

J 

H 

g 

s. 

g 

'% 

Is 

1 

1 

~S 

1 

i 

■i 

1 

s 

1 

;= 

1 

-^ 

1 

-% 

1 

375 

h. 

350 

\ 

r 

325 

^ 

/ 

300 

\ 

275 

/s 

J 

\ 

250 

/ 

225 

' 

I 

i 

200 

\ 

/ 

175 

\ 

150 

/ 

\ 

125 

\ 

\ 

100 

\ 

V 

75 

\ 

/ 

\ 

50 

V. 

■> 

/ 

\ 

25 

\/ 

^- 

^ 

\ 

.  y 

0 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

[V 



The  causes  for  this  remarkable  uniformity  in  the  relations  of  typhoid 
fever  to  season  are  as  yet  wholly  unknown.  The  universality  of  the 
relation,  its  recurrence  in  all  possible,  remotely  situated  regions,  indicate 
that  it  is  dependent  not  upon  local,  but  upon  general  conditions,  possibly 
such  as  are  responsible  for  the  power  of  multiplication  and  the  vital 
activity  of  the  typhoid  germ  itself.  Although  much  is  known  with 
regard  to  the  details  in  this  connection,  an  insight  into  the  solution  of 
general  questions  is  wanting,  particularly  the  relation  of  the  poison  to 
important  cosmic  conditions.  It  is,  therefore,  better  for  the  present  to 
leave  a  glaring  deficiency  rather  than  to  bridge  it  over  with  unstable 
theories. 

With  relation  to  the  influence  of  weather  and  temperature  in  the 
etiology  of  typhoid  fever  there  is  much  diversity  of  opinion  among 
writers,  and  there  exists  by  no  means  unanimity  with  regard  to 
season.  In  my  opinion  there  are  no  fixed  laws  in  this  regard.  Too 
much  importance  has  certainly  been  attached  to  isolated  impressions  and 
observations  in  some  endemics,  and  premature  generalizations  ha^^e  been 
made.  In  general,  it  may  be  said  that  in  most  localities  summer  heat 
and  dryness  render  probable  an  increase  of  typhoid  fever  in  the  autumn 
months — an  observation  that  is  in  accord  with  the  theory  of  Buhl  and 
Pettenkofer  and  led  up  to  the  ground-water  theory.  Whether  damp- 
ness and  cold  weather  operate  in  an  opposite  direction  is  still  doubtful. 
Careful  observers,  on  the  other  hand,  have  attempted  to  attribute  the 
development  and  the  increase  of  the  disease  in  some  places  to  these 


70  TYPHOID  FEVER. 

latter  conditions.  As  a  matter  of  fact,  it  is  readily  conceivable  that  the 
virus  accidentally  deposited  upon  the  surface  of  the  earth  or  in  the 
upper  layers  of  the  soil  may  l>c  carried  off  by  rain-water  or  melting 
snow,  and  be  disseminated  by  linding  its  way  into  water-conduits  or 
wells. 

Occurrence  of  the  Disease  in  General. — Sporadic  Cases; 
Endemics  and  Epidemics. — After  having-  considered  the  etiologic 
relations  m  detail,  and  having  presented  an  enormous  mass  of  individual 
experiences  and  facts,  a  fe^v  words  with  regard  to  the  general  character  of 
the  disease  and  its  general  manifestations  will  be  apjn'opriate.  In  this 
connection  also  marked  ditferences  from  other  infectious  diseases  are 
apparent,  especially  from  the  acute  exanthemata,  particularly  the  true 
pestilences — small-pox,  typhus  fever,  cholera,  and  i)lague.  As  has  been 
mentioned,  these  are  generally  confined  to  definite  portions  of  the  earth 
and  to  certain  countries  in  which,  like  a  fire  smouldering  beneath  the 
ashes,  they  occur  constantly,  but  within  narrow  limits,  and  then,  from 
time  to  time  flaring  up,  they  extend  over  great  distances  and  areas. 
The  pestilences  included  in  the  acute  exanthemata — variola  and  typhus 
fever — are  also  little  dependent  upon  the  season  of  the  year  or  upon  the 
age.  Typhoid  fever,  as  has  been  seen,  is,  on  the  contrary,  distributed 
over  the  entire  world.  Being  rather  dependent  upon  the  individual  and 
the  activity  of  human  intercourse,  it  almost  never  disa2)pears  in  popu- 
lous cities,  while  in  the  country  it  is  generally  absent  or  occurs  but 
occasionally. 

In  further  contrast  with  the  exauthematous  infectious  diseases, 
typhoid  fever  generally  occurs  in  sporadic  cases  or  in  groups  of  cases, 
occurring  in  dwellings  as  house-epidemics,  or  occasionally  spreading 
throughout  entire  streets,  if  the  conditions  for  conveying  the  infecting 
agent  are  accidentally  thus  uniformly  distributed.  By  the  juxtaposi- 
tion of  such  disease-foci,  or  less  commonly  from  the  outset,  owing  to 
most  favorable  modes  of  dissemination — water-conduits,  streams — actual 
epidemic  distribution  of  the  disease  may  result.  In  no  instance,  how- 
ever, does  rapid  dissemination  to  neighboring  coimtries  or  throughout 
the  entire  M^orld  take  place  from  such  a  focus  even  though  it  is  of  con- 
siderable or  of  large  size,  as  is  the  rule  with  typhus  fever,  cholera,  and 
plague.  Typhoid  fever  always  maintains  a  tendency  to  local  limitation, 
and  this  may  be  altered  only  by  special  conditions.  This  tendency  can 
be  readily  explained  ;  it  is  a  necessar}^  result  of  certain  characteristics  of 
the  typhoid  germ,  which,  as  has  been  seen,  is  not  easily  transmitted, 
but  only  exceptionally  is  carried  through  the  air,  and  then  only  for 
short  distances,  so  that  merely  being  near  the  patient,  without  contact,  is 


ETIOLOGY.  77 

free  from  danger  for  even  highly  predisposed  persons.  Only  by  direct 
conveyance  of  the  poison  or  conveyance  through  the  intermediation  of 
a  third  person,  and  then  only  by  way  .of  the  digestive  tract,  is  the 
disease  transmitted.  All  of  these  facts  were  long  ago  given  expression 
to  in  the  circumstance  that  typhoid  fever  was  not  included  among  the 
"  contagious  "  diseases,  but  received  the  designations  "  miasmatic  "  and 
"  contagious  miasmatic,"  which,  according  to  existing  views,  are  no 
longer  permissible. 

CONCLUSIONS. 

The  foregoing  considerations  have,  it  is  hoped,  shown  that  the  etiology 
of  typhoid  fever  appears  at  the  present  day  in  quite  different  light 
from  that  in  which  it  was  viewed  in  prebacteriologic  times.  It  will  be 
useful  to  summarize  what  has  thus  far  been  rendered  certain  or  probable. 

The  development  and  the  manifestations  of  typhoid  fever  are  depen- 
dent upon  the  lesions  in  the  human  organism  resulting  from  the  invasion 
and  the  vital  activity  of  the  Eberth-GafPky  bacillus.  The  typhoid- 
bacillus  is  not  identical  with  Bacillus  coli.  The  relations  that  exist 
between  the  two  micro-organisms,  and  their  degree  of  relationship,  must 
be  established  by  further  uivestigations.  The  growth  and  the  develop- 
ment of  the  typhoid-bacillus  take  place  exclusively  in  the  body  of  the 
typhoid  patient.  The  germs  are  thrown  off  especially  with  the  intestinal 
discharges  and  urine  of  the  sick,  and  give  rise  to  new  cases  of  the  disease 
principally  by  gaining  entrance  in  a  viable  condition  through  the  mouth 
and  the  stomach  into  the  intestinal  tract  of  predisposed  individuals.  The 
entrance  of  the  virus  through  the  air-passages  cannot  be  wholly  excluded, 
but  it  is  in  general  of  subordinate  importance.  It  is  for  this  reason  that 
mere  presence  in  the  vicinity  of  the  patient,  such  as  suffices  for  infection 
with  the  acute  exanthemata,  is  not  adequate  for  infection  of  even  the 
most  predisposed  individual  in  the  case  of  typhoid  fever. 

Typhoid  fever  does  not  belong  to  the  "  contagious  "  diseases  in  the 
older  significance  of  the  term.  The  typhoid  virus  is  conveyed  directly 
from  the  patient  and  his  dejections  or  through  household-articles  and 
healthy  third  persons — nurses,  attendants,  etc.  ;  or  by  reason  of  its 
marked  tenacity  it  remains,  under  the  most  varied  external  conditions, 
attached  to  various  media  and  for  a  long  time,  in  a  state  of  vitality,  in 
order  later  to  gain  entrance  into  the  human  being,  directly  or  indirectly. 
Typhoid  fever  may  be  conveyed  for  great  distances  by  means  of  the 
sick  themselves  or  by  germ-laden  media.  The  belief  that  the  bacillus 
after  leaving  the  body  requires  further  development  and  maturation 
outside  the  body  is  untenable  in  the  present  state  of  knowledge. 


78  TYPHOTD  FEVER. 

The  principal  carrier  aud  disseminator  of  the  typhoid  germ  is  water. 
Dissemination  of  the  typhoid  germ  in  the  dry  state,  attached  to  particles 
of  dust,  through  the  air  is  possible  but  unconnnou.  Tlie  «)])inion  for- 
merly held  that  typhoid  fever  results  from  the  swallowing  or  inhalation 
simj)ly  of  putrid  gases  has  been  wholly  abandoned,  Dejxtsited  in  the 
earth,  the  ty})hoid  germ  may  remain  capable  of  development  for  a  time, 
to  be  spread  from  this  point  through  various  accidental  conditions, 
among  which  entrance  into  subsoil-water,  well-water,  or  flowing  water 
plays  the  most  important  part.  A  local  predisposition  in  the  sense  of 
constant  impregnation  of  the  earth  in  a  given  locality  with  the  poison 
and  maturation  therein  cannot  be  accepted,  and  still  less  the  ])enetration 
of  the  poison  into  the  gronnd-air  and  infection  of  the  neighboring  people 
by  exhidations  from  the  earth. 

The  susceptibility  to  typhoid  fever  is  exceedingly  widesj)read.  No 
race  is  exempt  or,  so  far  as  experience  teaches,  materially  less  predis- 
posed. Typhoid  fever  has  been  observed  in  all  civilized  countries  of 
the  earth,  in  the  most  varied  climates  and  altitudes.  Young  persons 
and  adolescents  principally  are  predisposed  to  the  disease,  and  robust 
and  well-developed  individuals  in  general  more  so  than  the  weak  and 
those  debilitated  by  disease.  Children  under  the  age  of  one  year  are 
attacked  with  extreme  rarity.  After  the  fortieth  year  of  life  the  fre- 
quency declines  rapidly.  Sex  in  itself  has  no  marked  influence.  Possi- 
blv  men,  in  consequence  of  social  and  other  conditions  of  life,  are  more 
graitly  exposed  to  the  possibility  of  infection,  and  tlierefore  are  more 
frequently  attacked. 

Recovery  from  one  attack  of  the  disease  affords  in  the  majority  of 
cases  protection  from  subsequent  attacks  throughout  the  remainder  of 
life.  A  number  of  individuals  are  attacked  a  second  time.  The  occur- 
rence of  tln-ee  or  four  attacks  in  the  same  person  is  most  exceptional. 
Almost  everywhere,  especially  upon  the  continent  of  Europe  and  in 
England,  the  majority  of  cases  of  typhoid  fever  occur  in  the  latter  ])art 
of  tiie  vear — in  the  late  summer,  the  autumn,  and  the  early  Avinter 
montiis.  In  contrast  with  the  true  pestilences,  typhoid  fever  has  a 
tendency  to  confine  itself  locally,  so  that  it  commonly  occurs  in  sporadic 
cases  and  groups  of  such  cases — house-epidemics  and  street-epidemics 
— and  under  special  conditions  it  m:iy  be  distributed  over  an  entire  city 
or  localitv. 


PATHOLOGY.  79 


II.    PATHOLOGY. 

GENERAL   SYMPTOMATOLOGY. 

Few  acute  infectious  diseases  exhibit  such  great  variations  as  typhoid 
fever  in  their  manner  of  onset  and  their  course.  One  may  see  the  mild- 
est attacks,  lasting  only  a  few  days,  scarcely  compelling  the  patient  to 
take  to  his  bed,  even  scarcely  attended  with  appreciable  fever,  as  well 
as  severe  attacks,  lasting  many  weeks  or  even  months,  with  high  fever, 
most  profound  general  and  local  manifestations,  and  in  certain  cases  long 
protracted  convalescence  ;  and  if,  together  with  this  protracted  type  of 
disease,  other  cases  are  observed  in  which  the  disease,  setting  m  with 
unusually  severe  manifestations  from  the  outset,  rapidly  attains  an  alarm- 
ing intensity  and  progresses  uninterruptedly  to  death,  the  question  will 
repeatedly  arise  in  the  face  of  such  diversity  of  manifestations  :  Are 
they  to  be  referred  to  a  common  cause?  It  cannot  even  be  said  that 
age,  sex,  or  the  general  condition  of  the  body  exerts  a  definite  influence 
upon  the  course  of  the  disease.  Both  in  general  and  in  detail,  factors  of 
an  uncertain  character  are  here  to  be  dealt  with,  among  which  possibly 
the  intensity  of  the  infection,  certain  peculiarities  of  the  virus,  and  the 
predisposition  of  the  infected  individual  play  an  important  part.  Accord- 
ingly it  is  not  possible  to  give  a  general  description  of  the  course  of 
typhoid  fever.  It  will,  however,  be  useful,  in  connection  with  the 
further  discussion  of  the  subject,  to  sketch  in  outline  the  picture  of  a 
moderately  severe  or  severe  case  of  typhoid  fever  terminating  in  recovery 
in  a  previously  healthy  adult.  In  connection  with  this  description  the 
pathologic  anatomy  and  symptomatology  of  typhoid  fever  will  be 
described,  and  then  an  attempt  will  be  made  to  consider  the  various 
forms  of  course  in  so  far  as  they  have  theoretic  and  practical  significance. 

Period  of  Incubation. — From  the  moment  of  entrance  of  the 
germ  into  the  body  to  the  beginning  of  the  morbid  manifestation  to 
which  it  gives  rise,  a  most  variable  period  of  time  appears  to  elapse  in  a 
case  of  typhoid  fever.  It  is,  therefore,  far  more  difficult  to  determine 
the  period  of  incubation  than  in  the  case  of  some  other  acute  infectious 
diseases,  as,  for  instance,  the  acute  exanthemata.  Even  the  time  when 
the  coutagium  is  received  can  but  rarely  be  established,  as  this  is  not 
effected  by  mere  presence  in  the  neighborhood  of  the  patient  or  simple 
contact  with  him,  but  by  processes  that  are  not  susceptible  of  direct 
observation.     Nor  are  the  conditions  more  favorable  with  regard  to  a 


80  TYPHOID  FEVER.    ■ 

precise  determination  of  the  end  of  the  period  of  incubation  and  the 
beoinning  of  the  actual  disease,  the  dividing-line  between  which  is 
usually  indistinct.  Even  the  beginning  of  the  fever,  which  in  general 
is  stated  to  be  the  most  reliable  sign  of  the  beginning  of  the  actual 
disease,  is  subjectively  often  so  little  marked  that  even  intelligent 
patients  make  uncertain  statements  in  connection  therewith. 

Taking  all  of  this  into  consideration,  the  duration  of  the  period  of 
incubation  can  be  stated,  according  to  my  experience,  to  be  from  one  or 
two  to  three  weeks.  The  cases  are  worthy  of  little  credulity,  and  in 
any  event  are  susceptible  of  varying  intei'pretation,  in  which  only  a  few 
hours  elapse  bet\veen  infection  and  the  begmning  of  the  disease.  The 
observation  of  a  greatly  prolonged  period  of  incubation  appears  to  me  to 
be  more  probable.  Every  experienced  physician  has  observed  cases 
in  which,  many  weeks  before  the  outbreak  of  typhoid  fever,  general 
malaise  existed  that  upon  most  careful  examination  could  not  be 
referred  to  local  disease,  and  in  which  the  patients  dragged  tliemselves 
about  and  felt  as  if  something  were  wrong.  Such  ill-dctiued  languor 
and  indisposition  in  the  presence  of  normal  bodily  temperature  and 
absence  of  local  manifestations  are  usual  in  the  period  of  incubation 
of  typhoid  fever,  in  contrast  with  similar  periods  in  other  infectious 
diseases,  as,  for  instance,  the  acute  exanthemata  already  mentioned, 
which  generally  give  rise  to  no  manifestations  during  this  stage. 

An  attempt  has  been  made  to  divide  the  period  of  incubation  of 
typhoid  fever  mto  a  stage  of  complete  latency  and  a  true  prodromal  stage 
— that  is,  the  period  of  indefinite  bodily  disturbances.  This  is  pedantic 
and  useless.  It  is  best  to  say  that  the  period  of  incubation  is,  as  a  rule, 
occupied  wholly  or  in  part  by  morbid  manifestations,  while  a  smaller 
number  of  individuals  infected  with  typhoid  germs  may  remain  entirely 
free  from  symptoms  during  this  period.  An  estimate  of  from  5  to  1 0 
per  cent,  for  the  latter  group  will  prol)ably  not  be  too  high. 

Among  the  principal  manifestations  of  the  period  of  incubation, 
languor,  a  sense  of  drawing  in  the  extremities,  headache,  sacral  pain, 
disturbed  sleep,  at  times  wdth  night-sweats,  may  be  mentioned.  The 
appetite  is  generally  impaired,  nausea  is  present,  the  patients  complain 
of  a  sense  of  pressure  in  the  epigastrium,  and  often  the  bowels  are  con- 
stipated, although  diarrhea  also  may  be  observ'ed  at  this  stage.  Pre- 
viously healthy,  strong,  and  energetic  persons  continue  wholly  or  in 
part  in  the  pursuit  of  their  work,  and  even  women  may  continue  in 
their  activity.  Observations  of  the  bodily  temperature  at  this  time 
disclose  no  or  but  slight  deviations  from  the  normal,  even  in  such 
patients    as    already    exhibit    increased    susceptibility    to    temperature- 


PATHOLOGY.  81 

variations  and  are  readily  chilled  on  going  into  the  open  air  or  getting 
into  a  cold  bed. 

The  actual  commencement  of  the  disease  dates  from  the  time  when 
the  patients  exhibit  the  first  marked  febrile  symptoms.  Among  all  of 
the  signs  of  the  beginning  of  the  disease  these  can  be  best  determined 
objectively.  Although  some  clinicians  date  the  beginning  from  the. 
time  of  going  to  bed  or  the  appearance  of  diarrhea,  this  is  indefinite  and 
arbitrary.  The  duration  of  the  morbid  manifestations  in  well-developed 
cases  is  generally  from  three  to  six  weeks.  This  period  of  the  disease 
has  been  divided  into  various  stages,  namely,  that  of  invasion  and 
advance,  that  of  acme,  and  that  of  subsidence  of  the  symptoms  of  the 
disease.  Often,  a  classification  is  made  accbrding  to  weeks,  based  upon 
the  clinical  and  the  associated  anatomic  manifestations,  but  which  there- 
fore can  be  only  grossly  accurate  because  the  latter  appear  at  different 
times.  Thus  are  placed  the  development  of  the  typhoid  lesions,  with 
their  symptoms,  in  the  first  week ;  the  acme  of  the  disease,  with  the 
completion  of  intestinal  ulceration  and  exfoliation,  is  assumed  to  occur 
in  the  second  and  third  weeks ;  while  the  fourth  week  is  considered  that 
of  the  healing  of  the  anatomic  lesions  and  of  beginning  convalescence. 

In  contradistinction  to  other  infectious  diseases,  the  beginning  of 
the  febrile  stage  of  typhoid  fever  is  generally  marked  by  shght,  often 
repeated  chilliness.  This  is  so  much  the  rule  that  when  a  febrile  disease 
begins  with  a  single  severe  chill  almost  any  other  disease  than  typhoid 
fever  is  thought  of.  It  is  known  that  the  absence  of  chill  is  to  be 
referred  to  the  gradual  beginning  and  the  slow  ascent  of  the  fever. 
Although  not  a  few  patients  still  hold  out  bravely,  the  majority  gener- 
ally take  to  their  bed  after  the  first  chilliness. 

The  general  sense  of  illness  now  increases  pretty  rapidly,  and  also 
the  objectively  demonstrable  weakness  of  the  patient.  This  usually 
corresponds  with  the  increase  in  the  fever,  which  at  the  end  of  the  first 
week  may  give  rise  to  elevation  of  the  bodily  temperature  to  40°  C.  or 
over  during  the  evening.  The  pulse  is  generally  full,  of  good  tension, 
and  regular,  but  accelerated.  In  young,  previously  healthy  men,  and 
even  in  those  in  middle  life,  the  increase  in  pulse-frequency  is  generally 
relatively  not  so  great  as  the  elevation  of  temperature,  while  in  women 
and  children  the  pulse-rate  is  greatly  increased  and  appears  proportional 
to  the  elevation  of  temperature.  Toward  the  end  of  the  first  week  the 
pulse  is  often  already  dicrotic.  With  the  exception  of  children  and  the 
aged  and  previously  debilitated  individuals,  the  patients  appear  com- 
pletely sensible  during  this  period.  They  complain  of  headache,  ver- 
tigo, roaring  in  the  ears,  with  a  sense  of  intense  languor,  and  they  are 

6 


82  TYPHOID  FEVER. 

often  unable  to  secure  a  comfortable  jiosition  in  consequence  of  pain  in 
the  sacral  region  and  the  extremities.  Food  is  often  declined,  while 
intense  thirst  is  <2:onerally  present.  The  tongue,  at  first  still  moist, 
heavily  coated,  yellowish  white  or  brown,  and  also  the  mucous  mem- 
brane of  the  lips  and  the  mouth,  exhibit  a  tendency  to  dryness  toward 
the  end  of  the  first  week.  The  not  infrequent  occurrence  of  epistaxis 
at  this  time  is  quite  distinctive,  and  in  some  patients  this  may  occur 
during  the  period  of  incubation.  The  facial  expression  of  the  patient 
is  from  the  outset  apathetic,  the  features  relaxed,  the  cheeks  reddened, 
and  the  skin  feels  hot  and  dry.  Only  during  the  first  few  days  of  the 
fever  does  slight  sweating  still  exceptionally  take  place,  especially  during 
the  night. 

During  the  first  M'eek  there  are  generally  slight  manifestations  on  the 
part  of  the  respirator}^  organs.  A  number  of  patients  will  at  this  time 
exhibit  a  dry,  short  cough,  while  this  is  absent  in  others  at  first. 
Susceptible  patients,  it  is  true,  complain  now  and  again  of  increased 
difficulty  in  brciithing.  ObjectiAe  examination  of  the  lungs  generally 
discloses  nothing  to  account  for  this,  although  here  and  there  dry  rales 
may  be  audible. 

In  the  majority  of  cases  the  abdomen  is  at  first  of  normal  form  and 
not  distended.  Exceptionally,  some  meteorism  becomes  apparent  toward 
the  end  of  the  first  Aveek.  The  epigastrium  is  not  rarely  tender  on 
pressure,  while  palpation  in  the  right  iliac  fossa  does  not  elicit  any 
expression  of  pain.  In  the  majority  of  cases  the  bowels  are  normal  or 
constipated.  IjCss  commonly  there  have  been  a  few  loose  stools,  while 
diarrhea  alone  in  the  first  period  appears  to  be  less  frequent.  During 
the  last  days  of  the  first  week  some  patients  complain  spontaneously  of 
pain  and  heaviness  in  the  left  side.  In  others  increased  sensibility  is 
discovered  only  on  palpation,  and  is  dependent  upon  beginning  enlarge- 
ment of  the  spleen. 

Toward  the  close  of  the  first  week  the  patient  begins  to  approach 
the  acme  or  fastigium  of  the  disease.  During  the  following  week  and 
beyond,  the  condition  is  comparatively  severe.  From  the  anatomic  stand- 
point the  stage  is  that  of  completed  medullary  swelling  of  Peyer's  patches 
and  the  solitary  follicles  and  the  associated  and  progressive  necrosis. 
The  fever,  after  a  step-like  ascent  during  the  first  week,  reaches  its 
highest  point  at  the  beginning  of  the  second  week,  or  it  rises  to  a  slightly 
higher  level  up  to  the  middle  of  this  week.  The  temperature-curve  for 
a  period  of  a  week  or  a  week  and  a  half  pursues  the  course  of  a  remit- 
tent continued  fever,  the  variations  between  morning  and  evening  tem- 
perature scarcely  exceeding  the  normal.      In  milder  cases,   it  is   true, 


PATHOLOGY.  83 

the  daily  variation  may  now  be  more  considerable,  and  give  rise  to  an 
intermittent  type  of  fever  ;  while,  on  the  other  hand,  in  cases  of  especial 
severity,  abnormally  slight  variations  may  result  for  days  in  an  almost 
pure  continued  fever.  With  regard  to  the  degree  of  temperature  itself, 
this  in  cases  of  moderate  severity  will  rarely  be  less  than  39°  0.  in  the 
morning.  It  may  reach  40.5°  C  at  mid-day,  and  in  the  evening  it 
may  often  rise  still  higher,  up  to  41°  C.  and  even  above. 

With  increase  of  the  fever  the  complaints  of  the  patient  gradually 
cease.  He  lies  in  an  apathetic,  stuporous  state,  and,  although  at  first, 
in  so  far  as  beginning  impairment  of  hearing  permits,  he  sluggishly 
responds  to  questions,  it  becomes  increasingly  difficult  to  maintain  his 
attention.  Fortunately,  he  now  enters  a  state  of  narcosis.  Should  new 
complaints  arise  at  this  time,  or  should  previous  pains  increase  in 
intensity,  complications  should  be  looked  for. 

During  the  day  the  patients  seldom  sleep  deeply.  Generally,  they 
lie  with  open  or  half-closed  eyes,  in  a  flaccid  dorsal  decubitus.  The 
hours  of  greatest  elevation  of  temperature  are  often  occupied  by  delirium. 
The  facial  expression  gradually  becomes  drawn,  and  the  previous  red- 
ness is  replaced  by  pallor  with  slight  cyanosis.  The  mouth  is  half-open  ; 
the  upper  lip  retracted,  so  that  the  upper  teeth,  covered  with  a  fuligi- 
nous deposit,  are  exposed.  The  lips  are  dry,  covered  with  dark  crusts, 
and  readily  bleeding  from  slight  fissures.  The  tremulous  tongue 
exhibits  the  same  appearance,  and  toward  the  end  of  the  second  week 
it  becomes  small  and  thin  from  exfoliation  of  crusts  and  epithelium, 
with  a  smooth,  red  surface  and  persisting  dryness.  Viscid,  brownish, 
sanguinolent,  often  desiccated  mucus  adheres  to  the  reddened  pharyn- 
geal mucous  membrane,  the  soft  and  the  hard  palate.  The  voice  is 
likely  to  be  weak,  toneless,  and  at  times  possibly  hoarse.  In  uncom- 
plicated cases  the  pulse  is  still  full  and  regular,  though  accelerated,  and 
in  the  majority  of  cases  markedly  dicrotic.  The  bronchitic  manifes- 
tations, which  were  but  slight  during  the  first  week,  now  almost  con- 
stantly undergo  exacerbation.  The  dry  cough  not  rarely  annoys  and 
disturbs  the  patient.  Examination  of  the  lungs  discloses  the  signs  of 
diifuse  bronchitis,  especially  marked  in  the  posterior  inferior  portions, 
which  in  severe  cases  may  become  the  seat  of  hypostatic  or  other  forms 
of  inflammatory  consolidation. 

Upon  the  hot,  dry  skin  the  well-known  roseolse  appear  during  the 
first  days  of  the  second  week,  not  rarely  even  at  the  close  of  the  first 
week,  in  the  form  of  slightly  raised  hyperemic  spots  varying  in  size 
from  that  of  a  pinhead  to  that  of  a  lentil.  They  appear  earliest  upon 
the  abdomen,  the  back,  and  the  lower  half  of  the  chest,  extend,  if  present 


84  TYPHOID  FEVER. 

in  large  number,  to  the  upper  arms  and  the  thig-hs,  ^vhile  the  forearms 
and  the  legs  are  rarely  and  the  face  is  never  ()eeu])ied  by  them.  Their 
develojnnent  does  not  take  plaee  all  at  onee,  but  regularly  in  sueeessive 
crops  throughout  the  entire  second  and  into  the  third  week,  and  in  pro- 
tracted cases  still  later. 

The  abdomen,  which  in  the  first  week  of  the  disease  is  normal  or 
slightly  distended,  now  generally  becomes  more  markedly  distended, 
but  only  in  extremely  severe  cases  or  in  those  subjected  to  injudi- 
cious dietetic  treatment  does  the  abdominal  distention  attain  a  marked 
deo-ree.  In  not  a  few  cases  the  state  of  the  bowels  remains  normal 
or  constipation  is  present.  In  another  large  number  diarrhea  occurs, 
with  from  two  to  four,  rarely  more,  thin,  yellowish,  "pea-soup-like" 
evacuations  in  the  twenty-four  hours.  In  severe  cases  the  patient  is 
slow  to  ask  for  the  bed-pan,  and  in  a  number  the  stools  and  the  urine 
are  voided  mvoluntarily.  The  enlargement  of  the  spleen,  which  in  some 
cases  had  been  demonstrable  during  the  middle  or  at  the  end  of  the 
first  week,  now  often  becomes  distinct  below  the  costal  margin  or  makes 
itself  apparent  for  the  first  time.  At  times,  however,  its  demonstration 
is  rendered  difficult  by  the  marked  meteorism.  The  urine,  which  at  first 
was  abundant,  becomes  scanty  and  high-colored.  Generally,  it  contains 
a  moderate  amount  of  albumin — so-called  febrile  albuminuria  develo])ing. 

With  a  continuance  and  a  partial  exacerbation  of  the  symptoms 
described  the  patient  reaches  the  height  of  the  attack.  He  is  now  often 
completely  stuporous,  mutters  to  himself,  exhibits  jerking  of  the  tendons 
and  floccillation,  fails  to  ask  for  either  food  or  drink,  voids  the  stools  and 
urine  involuntarily,  and  presents  a  condition  most  alarming  to  the 
friends  and  the  family — and  not  without  reason.  Progressive  cardiac 
enfeeblement,  paralysis  of  the  nervous  centers,  complicating  inflamma- 
tory affection  of  the  lungs,  intestinal  hemorrhage,  peritonitis,  and  other 
complications  may  induce  a  fatal  termination,  but  fortunately  not  so  fre- 
quently as  the  laity  fears  if  appropriate  nursing  and  treatment  be  insti- 
tuted. The  majority  of  patients  enter  upon  the  stage  of  recovery  and 
convalescence  from  the  middle  or  the  end  of  the  third  week,  or  the 
beginning  of  the  fourth  week.  Naturally,  this  period  also  is  not  free 
from  danger.  There  may  be  recrudescences  and  relapses,  or  the  life  of 
the  patient  may  be  endangered  by  complications  and  exacerbations  of 
such  conditions  as  may  have  developed  during  the  acme  of  the  disease. 

The  transition  from  the  fastigium  to  the  stage  of  recovery  is  gener- 
ally attended  with  a  peculiar  change  in  the  course  of  the  temperature. 
The  curve,  after  at  times  marked  fluctuations  without  apparent  cause 
have   preceded,  becomes  more  or  less  markedly  and  often  extremely 


PATHOLOGY.  85 

intermittent,  with  a  declininjr  tendency.  This  is  designated  the  stage 
of  steep  curves.  The  pulse  is  now  smaller,  the  lumen  of  the  artery 
narrower,  the  dicrotism  has  disappeared,  and  the  more  nearly  the  tem- 
perature approximates  the  normal,  the  less  becomes  the  frefjuency  of 
the  pulse,  not  rarely  giving  way  to  bradycardia. 

Even  during  the  stage  of  steep  curves  the  skin  is  likely  to  be  moist 
at  times.  The  roseolae  gradually  fade,  and  they  are  often  replaced  by 
another  striking  condition,  namely,  miliaria  crystallina.  The  lips  and 
the  mucous  membrane  of  the  mouth  also  become  clean  and,  together 
with  the  tongue,  lose  their  dryness.  The  appetite  and  the  sense  of 
thirst  return,  and  the  patients  now  begin  to  ask  for  food — a  demand 
that  soon  becomes  more  urgent  and  which  often  gives  rise  to  annoy- 
ing differences  with  the  physician  and  the  attendants.  With  the  de- 
cline of  the  temperature  the  patients  begin  to  make  complaints.  They 
become  lacrunose  or  irritable — all  manifestations  of  returning  conscious- 
ness, and  at  the  same  time  of  an  appreciation  of  their  helplessness  and 
weakness,  which  are  shown  also  objectively  in  great  emaciation  and 
pallor.  Fortunately  for  the  patient,  sleep  returns,  and  with  a  disap- 
pearance of  nocturnal  restlessness  and  dreams  the  other  annoying 
manifestations  likewise  subside  gradually.  Above  all,  the  bronchitis 
disappears,  and  such  pneumonic  alterations  as  have  developed  subside. 
The  enlargement  of  the  spleen  diminishes ;  the  urine  becomes  more 
abundant  and  lighter  in  color,  again  free  from  albumin,  and  at  times 
is  even  voided  in  unusually  large  amount.  The  diarrhea  often  persists 
into  the  afebrile  period,  the  stools,  however,  gradually  acquiring  a 
darker  color. 

In  favorable  cases  the  patient  now  gradually  becomes  free  from 
fever.  Toward  the  end  of  the  third  or  in  the  fourth  week  the  previous 
physiologic  body-temperature  is  generally  resumed,  with  the  normal 
daily  fluctuations,  and  in  all  severe  cases  the  temperature  usually  falls 
still  further  below  the  normal,  so  that  morning  temperatures  of  36°  C. 
and  less,  and  evening  temperature  of  rarely  more  than  36.5°  C,  may 
be  the  rule  for  days  or  even  weeks.  The  pulse,  which  is  especially 
small,  often  infrequent  and  slow,  is,  like  the  body-temperature,  unstable 
and  readily  variable.  Slight  mental  or  physical  disturbances  give  rise 
to  slight  elevation  of  temperature,  and  cause  considerable  transitory 
increased  frequency  of  pulse.  In  other  respects  also  the  extremely 
debilitated  convalescents  are  readily  excited  without  feeling  especially  ill. 
At  this  time,  provided  there  be  no  complication  on  the  part  of  the 
digestive  organs,  the  patient  exhibits  great  hunger.  All  of  his  thoughts 
and  reflections  revolve  about  the  ingestion  of  food,  and  the  large,  covetous 


86  TYPHOID  FEVER. 

eyes  with  which  he  follows  every  movement  of  the  nurse  or  the  physi- 
cian, from  whom  he  hopes  for  fultilment  of  his  desires,  are  characteristic. 
It  has  already  been  indicated  that  during  the  period  of  involution 
and  that  of  convalescence  the  patient  is  exposed  to  the  danger  of  recru- 
descences and  relapses,  and  even  at  this  time  life  may  be  threatened  by 
hemorrhage  and  intestinal  perforation.  Among  the  remaining  dangers, 
bed-sores,  erysipelas,  and  abscesses,  the  sequehe  of  pneumonia,  esj)ecially 
pleurisy  and  empyema,  as  well  as  parotitis,  typhoid  laryngitis  witli 
ulceration  and  necrosis  of  cartilages,  may  be  mentioned.  Changes  in 
the  myocardium  also  may  at  this  time  assume  an  alarming  role.  Men- 
ingitis and  other  severe  disturbances  on  the  part  of  the  central  nervous 
system  are  ibrtunately  less  common.  All  of  these  and  still  other  dis- 
turbances subsequently  to  be  described  in  detail  may  quickly  cause  a 
fatal  issue  in  the  course  of  a  few  hours  or  days,  or  after  long-continued 
suffering  may  terminate  either  in  recovery  or  in  death.  How  frequent 
are  weeks  of  ho])e  and  fear,  and  finally  ever}^thing  to  have  been  in  vain  ! 
When  recovery  finally  takes  place  after  complicated,  long-protracted 
convalescence,  it  is,  fortunately,  more  frequently  complete  than  in  the 
case  of  many  other  infectious  diseases.  The  patients  generally  recover 
with  remarkable  rapidity  after  subsidence  of  the  local  manifestations, 
and  their  nutrition  improves,  so  that  they  present  the  well-known 
picture  of  the  contented,  fattened  typhoid  convalescent. 

SUMMARY  OF  THE  POST-MORTEM  CONDITIONS* 

The  following  section  will  be  comparatively  less  comprehensive  than 
some  others  in  this  work,  as  a  part  of  the  facts  that  might  be  considered 
here  will  be  treated  of  in  other  sections.  Thus,  for  convenience  in 
descriptions,  detailed  statements  as  to  the  mor|)hology  and  the  biology 
of  the  typhoid-bacillus  have  already  been  made  in  the  section  on 
Etiology  and  will  be  made  in  the  section  on  Diagnosis,  while  in  the 
section  devoted  to  an  analysis  of  the  individual  symptoms  it  was  impos- 
sible in  many  places  to  avoid  a  full  description  of  the  anatomic  altera- 
tions. I  believe  that  this  apparent  irregularity  has  rather  contributed 
to  comprehensiveness,  and  that  it  is  the  best  means  of  eliminating 
otherwise  unavoidable  repetition. 

EXTERNAL  APPEARANCES. 
Accordingly  as  death  has  taken  ])lace  during  the  first  stage  of  the 
disease,  whether  as  a  result  of  the  severity  of  the  infection  or  of  intes- 
tinal hemorrhage,  or  of  other  sudden  accident,  or  in  the  second  stage 
after  protracted  suffering  or  in  consequence  of  severe  complications,  the 


PATHOLOGY.  87 

external  appearances  of  the  body  may  be  diametrically  opposite.  In  the 
first  event  the  body  is  generally  well  nourished,  the  si<in  smooth  and 
tense,  the  layer  of  fat  often  well  developed.  Frequently  the  remains  of 
miliaria  crystallina  are  present,  wliile  roseola  or  traces  thereof  are  never 
appreciable.  The  muscles  are  dry,  tough,  and  dark  red.  The  blood 
exhibits  a  diminished  tendency  to  coagulation  and  is  exceedingly  dark. 
The  large  veins  are  generally  filled  with  dark,  loose  clots,  and  the  tissues 
are  generally  the  seat  of  considerable  imbibition  of  blood. 

The  bodies  of  those  dead  after  a  protracted  attack  of  the  disease 
often  exhibit,  in  contrast  to  the  conditions  just  described,  extraordinary 
emaciation,  with  a  pale,  desquamating  skin,  occasionally  abscesses, 
furuncles,  and  secondary  ulcers  of  considerable  size.  Not  rarely  bed- 
sores also  are  present.  At  times  there  is  edema  about  the  ankles.  The 
muscles  in  such  cases  are  wasted,  pale,  and  infiltrated  with  serum.  The 
blood  also  appears  lighter  and  diffluent,  with  a  tendency  to  the  forma- 
tion of  pale  or  wholly  colorless  clots.  Unless  profound  cardiac  or  pul- 
monary complications  are  present,  the  bodies  of  typhoid  jjatients  exhibit 
lividity  of  the  face  seldom  or  in  but  slight  degree.  Post-mortem  sug- 
gillation  also  is  comparatively  little  marked.  The  tendency  to  putre- 
faction does  not  occur  so  early,  and  is  not  so  marked  as  in  other  infec- 
tious diseases,  as,  for  instance,  typhus  fever  and  small-pox.  E,igor 
mortis  persists  for  a  relatively  long  time — at  any  rate,  longer  than  in 
typhus  fever. 

MUSCLES,  BONES,  AND  JOINTS. 

The  appearance  of  the  muscles  in  general  has  been  referred  to  in 
the  description  of  the  general  appearance.  Their  condition  is,  however, 
when  considered  in  detail,  often  strilving,  particularly  when  death 
has  occurred  at  the  height  of  the  disease.  The  dry,  brownish-red 
muscles,  resembling  smoked  meat  and  presenting  a  dull  luster  on  sec- 
tion, are  friable,  although  they  appear  firm  to  the  touch.  In  places 
they  present  a  striate  or  punctate,  grayish-yellow  or  pale-yellow  discol- 
oration. At  times  entire  groups  of  muscles  acquire  this  appearance, 
especially  in  cases  in  which  death  occurs  from  the  middle  of  the 
third  to  the  fourth  week  of  the  disease,  or  even  later.  These 
alterations  may  actually  involve  all  of  the  voluntary  muscles  of  the 
body.  They  are  most  frequently  evident  in  the  large  thoracic  muscles, 
the  abdominal  recti,  and  the  muscles  of  the  thighs,  especially  the  adduc" 
tors.  Not  rarely  the  muscles  of  the  tongue  and  of  the  diaphragm 
appear  to  be  involved. 

The  rriuscles,  when  most  affected,  frequently  exhibit  ruptures, 
together  with  extravasations  of  blood — an  indication  that  they  are  not 


88  TYPHOID  FEVER. 

of  ])ost-mortom  origin,  htit  have  developed  during  lite.  Although  these 
muscular  lac'ei*atiou.s,  to  Mhich  K(^)kitansky  iirst  and  Yirchow  t^ubse- 
queutly  called  attention,  occur  also  in  the  course  of  other  acute  infectious 
diseases,  as,  for  instiince,  typhus  fever,  they  appear  to  be  especially 
fVequent  aiid  extensive  in  cases  of  typhoid  fever. 

The  microscopic  appearance  of  the  muscles  affected  in  the  maimer 
described  was  studied  with  especial  care  by  Zenker,  \\ho  distinguished, 
in  addition  to  simple,  non-degenerytive  atrophy,  two  other  varieties  of 
degeneration,  the  granular  and  fatty,  and  the  waxy,  Avhich  he  found 
generally  associated  or  combined.  The  portions  of  muscle  undergomg 
waxy  degeneration,  especially  between  the  second  and  the  fourth  week 
of  the  disease,  exhibit  the  firm  consistency  already  mentioned,  and 
an  appearance  at  first  striate  and  punctate,  then  grayish  red,  and  sub- 
sequently waxy  gray  or  fish-meat-like ;  while  the  granular  and  fatty 
degeneration  becomes  manifest  by  change  in  color,  marked  pallor  or 
yellowish  discoloration,  only  after  it  has  existed  for  a  long  tune  and 
has  attained  a  high  grade  of  intensity.  The  appearance  of  the  degener- 
ated muscles  may  further  become  especially  conspicuous  from  the  fact 
that  the  hemorrhages  previously  mentioned  may  be  associated  with 
the  degeneration.  At  times  the  extravasations  of  blood  appear  as 
striate  and  punctate  figures,  while  at  other  times,  as  has  been  mentioned, 
they  form  extensive  hemorrhagic  collections  with  destruction  of  the  mus- 
cular tissue.  The  distribution  of  these  lacerations  and  hemorrhages 
throughout  the  muscular  system  is  quite  irregular,  in  contrast  with  the 
distribution  of  waxy  degeneration,  which  often  is  symmetrical.  Natu- 
rally, they  will  be  found  most  frequently  in  those  situations  that  are 
mvolved  in  the  degenerative  process  in  greatest  degree  and  earliest. 
Accordingly,  their  principal  seat  is  the  abdominal  rectus,  more  often  the 
loAver  than  the  upper  half,  the  greater  and  lesser  pectoral,  and  the  ilio- 
psoas. I  have  observed  them  in  a  niunber  of  instances  in  the  biceps  and 
triceps  of  the  arm,  and  remarkably  seldom  in  the  adductors  of  the  thigh, 
considering  their  frequent  involvement  in  the  waxy  form  of  degeneration. 
The  further  disintegration  of  such  foci,  with  the  peculiar  changes  in 
their  contents,  has  often  given  rise  to  the  opinion  that  muscle-hemato- 
mata  may  undergo  suppuration.  Although,  from  existing  bacteriologic 
knowledge,  this  possibility  cannot  be  wholly  excluded,  yet  it  must  be 
exceedingly  uncommon.  True  muscle-abscesses  in  the  course  of  typhoid 
fever  appear  to  be  rare.  I  have  observed  them  in  a  number  of  instances 
as  part  manifestation  of  secondary  septic  processes.  Recently,  attention 
has  been  repeatedly  called  to  muscle-abscesses  due  to  the  pyogenic 
activity  of  the  typhoid-bacillus. 


PATHOLOGY.  89 

Thus,  Cahradnicky  ^  has  observed  during  life  an  abscess  as  large  as  an 
egg  in  the  greater  pectoral  muscle  which  contained  only  typhoid-bacilli. 
This  case  is  especially  interesting  further  on  account  of  the  demonstration  of 
the  great  persistence  of  the  Eberth  bacillus  in  the  living  body.  The  indi- 
vidual, who  was  subjected  to  operation  in  Decend)er,  1894,  had  had  an 
attack  of  typhoid  fever  in  September,  1893. 

The  bones  and  the  joints  are  involved  mucli  less  commonly, 
thouffh  in  a  more  varied  mcinuer.  Attention  bus  been  directed  to  these 
lesions,  especially  through  the  work  of  Keen.^  In  his  later  work  he 
collected  237  cases  of  ostitis  and  periostitis,  and  since  then  numerous 
other  cases  have  been  reported.  So  far  as  bacteriologic  investigations  at 
present  go,  not  a  small  number  of  cases  of  periostitis  and  osteomyelitis 
in  the  course  of  typhoid  fever  are  due  to  the  bacillus  of  Eberth  (Cornil 
and  Peau  ^).  This  organism  was  isolated  in  pure  culture  from  4  out 
of  5  cases  reported  by  Parsons.*  From  the  fifth  case  Staphylococcus 
pyogenes  was  isolated  as  well  as  Bacillus  typhosus.  Typhoid  periostitis 
and  the  generally  associated  inflammation  of  the  contiguous  superficial 
portions  of  bone  usually  occur  during  the  latter  course  of  the  disease,  at 
the  earliest  during  the  period  of  steep  curves,  but  generally  during  the 
first  part  of  convalescence,  but  may  occur  late  in  convalescence,  and 
eve.a  months  or  years  after  the  attack  of  fever.  Bruin''  has  reported 
one  case,  from  which  the  typhoid-bacillus  was  isolated,  occurring  six 
)'ears  after  the  primary  attack ;  and  Bruschke  ^  has  reported  one  occur- 
ring seven  years  afterward.  Quincke  *"  has  found  the  bacilli  m  the  bone- 
marrow  during  the  disease,  and  in  some  cases  as  long  as  four  months 
after  convalescence.  It  is  probable  that  they  may  remain  quiescent  in 
the  bone-marrow  for  very  long  periods  of  time,  and  only  give  rise  to 
inflammatory  conditions  when  a  condition  of  localized  lowered  resist- 
ance, possibly  due  to  injury,  occurs.  Young  persons,  and  generally 
those  at  about  the  age  of  puberty,  are  preferably  attacked.  I  have, 
however,  observed  the  condition  also  in  young  children  and  isolated 
instances  in  elderly  mdividuals  ;  once,  for  instance,  in  a  woman,  forty- 
seven  years  old.  The  long,  hollow  bones,  and  among  these  the  femur 
and  the  tibia,  are  attacked  most  frequently ;  also  the  sternum  and  the 
ribs  (Helferich)  have  been  involved  in  isolated  instances.  In  young 
persons  the  process  in  the  long  bones  begins  preferably  in  the  region  of 
the  epiphysis. 

1  Wie7i.  klin.  Rundschau^  1895,  No.  43. 

2  "Toner  Lectures,"  1876,  Smithsonian  Miscellaneous  Collections,  No.  800.  Also, 
The  Surgical  Complications  and  Sequels  of  Typhoid  Fever,  Philadelphia,  1898. 

^  Bull,  de  I'Acad.  de  Med.,  1891.  *  Johns  Hopkins  Hospital  Reports,  vol.  v. 

s  Ann.  de  I'Inst.  Pasteur,  1896.  ^  Fortschr.  der  Med.,  1894. 

''  Berlin,  klin.   Woch.,  1894. 


90  TYPHOID  FEVER. 

The  disease  of  the  bone  may  occur  in  ouv  or  in  several  ])arts  of  the 
skeleton  at  the  same  time.  Occasionally,  it  is  confined  to  a  small  area, 
and  may  undergo  involution  ^vithout  injury  to  the  bone ;  while  in  other 
instances  periostitic  abscesses  may  develop,  ^^•ith  extensive  necrosis  of 
the  bone,  and  even  rupture  into  the  joint,  with  all  of  the  concomitant 
dangers.  Termination  in  the  formation  of  exostoses,  which  has  been 
mentioned  especially  by  French  clinicians,  appears  to  be  exceedingly 
rare. 

Typhoid  aifections  of  the  joints,  which  may  appear  as  monarticular 
or  polyarticultu',  and  as  suppurative  or  simple  inflammatory  serous  proc- 
esses (Keen,  Stromeyer,  Volkmann),  have  hitherto  received  little  thorough 
anatomic  study.  The  suppurative  lesions  appear  almost  always  to  be 
the  result  of  complicating  septicemia.^  Ponfick  ^  has,  however,  made  a 
thorough  study  of  the  changes  in  the  bone-marrow,  and  has  discovered 
conditions  suggesting  those  present  in  the  spleen  and  the  lymphatic 
glands.  He  describes  peculiar  large  cells,  containing  as  many  as  20  red 
blood-corpuscles  and  more,  in  the  bone-marrow  of  those  dead  at  the 
height  of  the  disease.  During  convalescence  these  structures,  previously 
mentioned  by  Neumann  and  Bizzozero,  evidently  undergo  such  trans- 
formation that  the  red  blood-coi'puscles  are  transformed  into  large 
clumps  of  pigment  or  masses  of  tine,  dark  granules.  When  these 
cells  are  present  in  large  number  they  impart  a  brownish-red  color 
to  the  bone-marrow,  which  persists  for  some  time  after  complete 
recovery  has  taken  place. 

DIGESTIVE  ORGANS. 
Reference  to  the  condition  of  the  tongue  and  the  mucous  membrane 
of  the  mouth  and  pharynx  has  already  been  made  in  the  description  of 
the  general  symptomatology.  Further  consideration  of  this,  especially 
to  the  interesting  typhoid  lesions  of  the  fauces  and  the  pharynx,  referred 
to  by  Louis  and  Jenner,  will  be  given  under  the  symptomatology.  In 
the  dead  body  they  are  represented  by  rounded  ulcers  of  varying  size, 
at  times  confluent,  rarely,  however,  of  great  extent,  but  exceedingly 
shallow,  and  covered  by  a  thin,  grayish-yellow,  readily  detached 
deposit.  Louis  claims  to  have  observed  similar  changes  down  into  the 
esophagus.  It  should  be  mentioned  additionally  that,  according  to 
HofPmann,  the  muscular  structure  of  the  tongue  is  not  rarely  involved 
in  waxy  degeneration.  Further  details  with  regard  to  the  salivary 
glands  w'ill  be  given  in  connection  with  the  analysis  of  the  individual 

1  Ebermayer,  Deutsch.  Arch.  f.  kiln.  Med.,  1889,  Bd.  xliv. 

2  Virchow's  Archiv,  1872,  Bd.  Ivi. 


PATHOLOGY.  91 

symptoms.  At  this  place  it  will  only  be  mentioned  that  they  are  often 
found  enlarged  when  dcatli  has  taken  place  at  an  early  stage  of  the  dis- 
ease. They  then  appear  firmer  than  normal,  darker,  discolored  brown- 
ish yellow  or  yellowish  red,  and  on  microscoj)ic  examination  they 
exhibit,  in  addition  to  evidences  of  hyperemia,  cloudy  swelling  of  the 
glandular  cells. 

The  stomach  and  the  upper  part  of  the  intestine  occupy  a  subordi- 
nate place  in  relation  to  the  remainder  of  the  small  intestine,  the  large 
intestine,  and  the  rectum,  with  regard  to  their  anatomic  lesions. 
Even  the  earlier  observers  and  all  of  those  who  followed  them 
mention  the  occurrence  of  detachment  and  punctate  redness  of  the  gas- 
tric mucous  membrane,  particularly  in  the  vicinity  of  the  pylorus,  at 
times  with  numerous  superficial  erosions,  or  a  marked  mammillated 
appearance.  Louis  had  already  shown  that  these  lesions  represent 
nothing  at  all  specific.  Ulceration  of  the  esophagus  and  stomach  occa- 
sionally occurs.  MitchelP  has  reported  such  a  case  and  reviewed  several 
others.  From  none  of  these  have  typhoid-bacilli  been  isolated,  and  they 
are  probably  due  to  a  secondary  process.  Stricture  of  the  esophagus 
following  typhoid  fever  rarely  occurs.  Such  cases  have  been  reported 
by  Packard,^  Mitchell,^  and  others.  Probably  this  condition  is  due  to 
a  cicatrization  of  the  secondary  ulcers.  The  attempts  of  Cornil*  and 
Chauffard  ^  to  establish  a  peculiar  typhoid  affection  of  the  stomach  in  the 
form  of  focal  accumulation  of  lymphatic  elements  in  the  mucous  mem- 
brane yet  requires  corroboration.  In  the  duodenum  also  at  times,  in 
my  experience  less  commonly  than  in  the  stomach,  swelling  and  red- 
ness of  the  mucous  membrane  are  present.  In  one  instance  I  observed 
superficial  erosions.  Specific  lesions  of  tliis  portion  of  the  mtestine  have 
likewise  not  as  yet  been  demonstrated  with  certainty. 

Of  enormous  importance  and  dominating  the  entire  picture  of  the 
anatomy  of  typhoid  fever,  however,  are  the  lesions  present  in  the  middle 
and  lower  portions  of  the  intestine,  from  the  lower  third  of  the  jejunum 
downward.  Before  entering  upon  a  detailed  consideration  of  these, 
some  general  statements  as  to  the  anatomic  and  topographic  conditions 
may  be  made.  In  accordance  with  the  conditions  present  toward  the 
close  of  life,  the  bodies  of  those  dead  of  typhoid  fever  frequently  exhibit 
meteorism.  This  is  likely  to  be  especially  marked  and  miiform  in  distri- 
bution in  all  parts  of  the  digestive  tube  only  when  extensive  peritonitis 
is  present.     When  this  is  absent,  the  distention  involves  preferably  the 

^  Johns  Hopkins  Hosp.  Rep.,  vol.  viii.  ^  Phila.  Med.  Jour.,  1898. 

*  Loe.  cit.  *  Gaz.  hebdom.  des  Sci.  7ned.,  1880. 

5  These  de  Paris,  1882. 


92  TYPHOID  FEVER. 

large  intestine,  and  generally  the  small  intestine  in  less  degree.  When 
the  colon  is  uniLsually  long  or  occnpies  an  abnormal  situation,  or  exhibits 
aty})ical  arraugemont  ol"  its  convohitions,  tlie  small  intestine  may  be 
entirely  covered  by  it.  The  lower  portion  of"  the  ileum  is  often  of 
normal  caliber,  or  even  contracted.  The  upper  portions  of  the  small 
intestine  often  exhibit  moderate  or  even  marked  meteorism.  Generally, 
on  external  inspection  of  the  ileum,  especially  its  lower  portions,  dark 
linear  spots  can  be  seen  opposite  the  attachment  of  the  mesentery.  On 
})al})ation  these  exhibit  a  denser  consistency  than  the  remainder  of  the 
intestinal  wall,  and,  as  will  be  disclosed  on  opening  the  intestine,  they 
correspond  to  the  specific  typhoid  intestiaal  lesions.  This  condition  is 
dependent  upon  a  peculiar  inflammatory  iliyperplasia  of  the  lymphoid 
structures,  which,  in  accordance  with  its  seat  in  the  small  or  the  large 
intestine,  occurs  as  hyperplasia  of  Peyer's  patches  or  of  the  solitary 
follicles. 

Bretonneau  was  probably  the  first  who  directed  attention  emphatically 
and  intelligently  to  the  typhoid  lesion  of  the  intestine.  He  considered  it 
specific,  although  he  compared  it  with  the  variolous  lesion  of  the  external 
integument.  Similar  opinions  have  been  expressed  by  other  observers  of 
the  same  and  of  a  later  period.  In  the  celebrated  book  of  Louis,  ho\Yever, 
esi>ecially  in  the  second  edition,  the  intestinal  lesion  is  clearly  recognized 
and  in  the  main  thoroughly  described. 

In  the  detailed  description  of  the  typhoid  intestinal  lesion  several 
stages  are  appropriately  recognized  :  1,  the  stage  of  hyperemia  ;  2,  that 
of  medullary  infiltration  ;  3,  that  of  necrotic  destruction  and  ulceration  ; 
and  4,  that  of  cicatrization.  In  general  these  anatomic  stages  corre- 
spond with  certain  portions  of  the  clinical  course.  It  shoidd,  however, 
be  borne  in  mind  that  the  intestinal  lesion  does  not  develop  and 
extend  simultaneously  and  imiformly,  but  rather  in  stages,  often  dis- 
tributed over  a  considerable  period  of  time,  and  it  likewise  mider- 
goes  involution  in  a  corresponding  manner.  The  lower  portion  of 
the  ileum  and  the  neighborhood  of  the  ileocecal  valve  are  generally 
attacked  earliest.  Often  the  impression  is  created  as  if  the  process 
extended  gradually  or  in  stages  from  this  point.  But  if  it  be  taken 
into  consideration  that  relapses  and  recrudescences  of  typhoid  fever  are 
attended  with  renewed  involvement  of  the  intestinal  mucous  membrane, 
it  can  be  understood  that  by  no  means  rarely  the  various  stages  of 
the  specific  lesion,  namely,  infiltration,  sloughing,  ulceration,  and  even 
complete  cicatrization,  can  be  studied  in  the  same  portion  of  the 
intestine. 

The  first  stage,  that  of  hyperemia  of  the  intestinal  mucous  mem- 
brane,  which  probably   occupies   the  beginning  of  the   first  week,   in 


PATHOLOGY.  93 

isolated  instances  even  the  entire  week,  is  not  understood  in  detail,  on 
account  of  the  exceeding  rarity  with  which  opp(jrtunity  for  anatomic 
investigation  is  afforded.  Rokitansky  and  Trousseau  believed  that  at 
this  time  hyperemia  of  Peyer's  patches  and  the  solitary  follicles  occurs 
as  the  forerunner  of  medullary  infiltration ;  Cornil  and  lianvier  also 
claim  to  have  made  similar  observations.  In  a  case  of  suicide  I  have 
observed  in  the  middle  of  the  first  week  detachment  and  marked  hyper- 
emia of  the  mucous  membrane  of  the  cecum,  the  adjacent  portions  of 
the  ileum,  and  the  colon,  with  slight  swelling  of  the  agminate  and  soli- 
tary follicles.  The  frequency,  the  extent,  and  the  depth  of  these  altera- 
tions in  the  individual  case,  whether  they  may  be  wanting,  whether  in 
cases  of  so-called  abortive  typhoid  fever  they  do  not  give  rise  to  further 
lesions,  whether  in  certain  varieties  of  the  disease  the  diffuse  catarrhal 
swelling  of  the  intestine  reaches  especially  high  grades  of  intensity, 
are  all  questions  that  await  answers  based  upon  more  extensive 
experience. 

With  the  beginning  of  the  second  week,  in  severe  cases  probably  at 
the  end  of  the  first,  medullary  infiltration  takes  place,  probably  "svith  a 
lessening  of  the  diffuse  hyperemia  and  swelling  of  the  mtestinal  mucous 
membrane.  In  general,  Peyer's  patches  appear  to  be  somewhat  in 
advance  of  the  solitary  follicles  with  regard  to  the  evolution  of  the 
process.  Not  rarely  entire  changes  are  observed  uniformly  in  both, 
while  infiltration  of  the  solitary  follicles  preceding  that  of  Peyer's 
patches  does  not  appear  to  be  frequent. 

In  their  form  and  situation,  the  typhoid  lesions  naturally  corre- 
spond in  general  to  their  anatomic  substratum.  They  are  oval,  with 
their  longitudinal  axis  corresponding  to  that  of  the  intestine,  are 
situated  principally  in  that  portion  of  the  intestinal  canal  opposite 
the  mesenteric  attachment,  and  generally  appear  as  sharply  circum- 
scribed, disk-shaped,  even  fungus-shaped  formations  with  overhanging 
margins.  At  first  greatly  reddened,  they  subsequently  acquire  a  grayish- 
red  or,  at  the  beginning  of  exfoliation,  a  grayish-yellow  color.  The 
surface  of  the  patches,  which  may  project  from  3  to  5  or  even  up  to  8 
mm.  above  the  intestinal  mucous  membrane,  is  at  times  smooth,  at 
other  times  slightly  granular  or  even  somewhat  nodular.  These  irregu- 
larities are  doubtless  due  to  the  fact  that  some  follicles  entering  into  the 
formation  of  the  patch  have  not  yet  become  completely  confluent  or,  at 
least,  are  not  swollen  to  the  level  of  the  surrounding  tissues.  The  con- 
sistency, the  degree  of  infiltration,  and  the  depth  to  which  they  extend 
are  extremely  variable  in  different  cases.  Even  at  the  present  time, 
French  clinicians  are  in  the  habit  of  makmg  certain  distinctions  in  this 


94  TYPHOID  FEVER. 

respect.  According  to  them,  the  soft  patches  and  the  hard  patches  of 
Li)uis  play  an  important  role  that  is  not  quite  comprehensible  from  onr 
present  point  of  view. 

The  medullary  swelling  is  by  uo  means  always  confined  to  the  limits 
of  the  patches,  .  At  times  the  infiltration  extends  beyond  them  to  the 
adjacent  mucous  membrane.  Under  such  circumstances  several  infil- 
trated patches  may  coalesce,  and,  in  consequence,  peculiarly  shaped 
elongated  formations  in  the  direction  of  the  axis  of  the  bowel  may  often 
result.  In  other  cases,  on  the  other  hand,  the  patches  are  only  partly 
involved  in  infiltration.  (lenerally,  the  coalescence  of  the  infiltrated 
portions  occurs  preferably  and  most  extensively  in  the  lowermost  por- 
tions of  the  ileum  just  above  the  ileocecal  valve  and  in  the  adjacent 
portions  of  the  cecum. 

The  infiltration  of  the  solitary  follicles  commonly  present  in  addition 
to  the  swelling  of  the  })atches,  and  exhibiting  in  different  cases  the  most 
varied  distribution  throughout  the  large  intestine,  and  at  times  extend- 
ing into  the  sigmoid  flexure  and  even  into  the  rectum,  gives  rise  to  the 
formation  of  roundish,  grayish -red  or  greatly  reddened  elevations,  fre- 
quently surrounded  by  a  garland  of  vessels.  They  project  above  the 
mucous  membrane  to  the  size  of  a  pea  and  larger,  and,  like  the  patches, 
not  rarely  exhibit  an  extension  of  the  infiltration  beyond  the  original 
limits  of  the  follicles.  They  may  then  develop  into  large  fungus-shaped 
formations  up  to  three-quarters  of  an  inch  in  diameter.  With  the  com- 
mencement of  involution  they  generally  assume  a  yellowish  color,  and 
then,  especially  if  of  moderate  size,  acquire  a  pustular  appearance.  The 
continuance  of  medullary  swelling,  in  both  the  agminate  and  the  soli- 
tary follicles,  is  brief.  Already  in  the  second  week,  often  at  its  begin- 
ning, involution  sets  in.  Cases  of  commencing  exfoliation  as  early  as 
the  fifth  and  the  sixth  day  of  the  disease  have  been  recorded.  In  con- 
trast with  these,  it  is  true,  observations  also  have  been  made  in  which 
the  infiltrations  exhibited  no  sign  of  commencing  disintegration  at  the 
end  of  the  second  week.  It  may  be  objected  to  these  statements  that 
the  determination  of  the  exact  day  of  the  disease  is  difficult,  but,  as  a 
result  of  unequivocal  personal  observation,  I  believe  that  they  are  well 
founded. 

Involution  of  the  medullar}^  swelling  may  in  general  V)e  brought 
about  in  one  of  two  ways  :  either  in  the  form  of  actual  absorption  of 
the  pathologic  products,  or,  as  is  by  far  the  more  common  method,  in  the 
form  of  necrosis,  with  subsequent  exfoliation  and  the  formation  of  cor- 
responding ulcers.  Both  of  these  varieties  of  involution  are  frequentl}^ 
observed  in  the  same  intestine ;  even  in   the  same  patch,  simple  absorji- 


PATHOLOGY.  95 

tion  quite  commonly  occurs  in  association  with  ulcerative  processes. 
If  it  be  remembered,  as  has  been  indicated,  that  the  various  stages  of 
the  lesions  in  the  same  body  generally  exhibit  various  grades  of  evolu- 
tion and  involution  according  to  the  portion  of  the  bowel  involved,  it  can 
be  comprehended  that  occasionally  almost  all  of  the  anatomic  processes 
described  may  be  observed  at  the  same  time  in  the  same  bowel.  Just 
as  in  respect  to  infiltration,  with  regard  to  regressive  alterations,  so 
the  Peyer's  patches  are  generally  somewhat  in  advance  of  the  solitaiy 
follicles.  With  reference  to  the  regressive  changes  in  detail,  the  infil- 
trations that  disappear  by  absorption  generally  at  first  present  a  grayish- 
yellow  discoloration,  and  then  progressively  collapse,  at  first  at  the 
center  and  from  this  point  toward  the  periphery.  In  the  parts  involved 
in  necrosis,  the  first  indication  of  this  process  consists  in  a  certain  spongi- 
ness  and  swelling  of  the  tissue,  frequently  with  reactive  redness  and 
tumefaction  of  the  surrounding  mucous  membrane.  The  patches  and 
follicles  then  acquire  a  grayish-yellow,  next  a  pale-yellow  or  dirty  gray- 
ish-yellow color,  and  soon  become  from  dirty  brownish  green  to  dark 
olive  green  from  imbibition  of  the  contents  of  the  intestines,  especially 
bile,  so  that  the  intestine  in  consequence  presents  to  the  inexperienced 
observer  a  most  remarkable  appearance. 

As  to  the  immediate  cause  of  the  necrosis,  Virchow  was  of  the 
opinion  that  it  is  a  form  of  caseation  much  like  that  occurring  in  tuber- 
culosis ;  while  Orth  thinks  that  it  is  an  anemic  necrosis  due  to  pressure 
exerted  on  the  blood-vessels  in  consequence  of  the  great  hypei'plasia  of 
the  cells.  In  this  connection  the  work  of  Mallory  ^  on  the  histologic 
changes  in  typhoid  fever  should  be  mentioned.  He  concludes  that,  due 
to  the  action  of  a  toxin  produced  by  the  typhoid-bacillus,  there  is  a  pro- 
liferation of  endothelial  cells.  These  cells  are  phagocytic  in  character, 
and  the  swelling  of  the  intestinal  lymphoid  tissue  is  due  almost  entirely 
to  their  formation.  The  necrosis,  he  thinks,  is  due  to  occlusion  of  the 
veins  and  capillaries  by  fibrinous  thrombi  which  owe  their  origin  to 
degeneration  of  phagocytic  cells  beneath  the  lining  endothelium  of  the 
vessels.  He  describes  a  similar  process  occurring  in  the  mesenteric 
glands  and  the  spleen. 

The  process  of  exfoliation  is  rarely  equally  advanced  and  equally 
deep  at  all  parts  of  one  patch  of  Peyer,  so  that  eschars  are  generally 
not  thrown  off  in  one  piece.  This  takes  place,  as  a  rule,  in  larger  or 
smaller  particles,  in  one  situation  more  superficially  and  in  another  more 
deeply.  Patches,  in  which  between  still  sloughing  portions  ulcerated 
areas,  in  consequence  of  exfoliation,  are  already  present,  generally  acquire 
^  Jour.  Exp.  Med..,  vol.  iii. 


96  TYPHOID  FEVER. 

a  peculiar  irregular  appearance.  These  have  been  designated  plaques 
gaufrees  by  Louis.  The  nioie  rare  exfoliation  of  the  sloughs  as  a  whole 
takes  place  preferably  in  tae  extremely  dense  areas  and  in  those  pre- 
senting deep  infiltmtion  (plaques  dures). 

The  ulcers  left  after  exfoliation  of  the  sloughs  attain  a  variable  depth 
in  accordance  with  the  extent  of  the  antecedent  infiltration.  At  tmies  they 
scarcely  penetrate  the  mucous  membrane ;  at  other  times  they  extend 
down  to  the  muscular  coat  or  even  destroy  a  layer  thereof;  and  at  still 
other  times  the  entire  muscular  coat  is  destroyed,  so  that  the  ulcer" 
extends  to  the  serous  layer.  Even  this  is  often  greatly  thinned,  even 
down  to  a  delicate  membrane.  The  margms  of  the  ulcers  are  sharp,  and, 
particularly  at  the  beginning,  are  steep  in  consequence  of  still-existing 
uifiltratiou  in  the  neighborhood  ;  the  latter,  however,  soon  disappears. 
The  edges  are  generally  little,  if  at  all,  detached.  The  base  of  the  ulcer 
presents  a  more  or  less  dark-red  appearance  shortly  after  exfoliation  has 
been  completed,  and  it  is  often  still  covered  in  various  places  witli  small 
remains  of  sloughs.  The  older  portions  soon  exhibit  a  slaty  discolora- 
tion. The  intestinal  ulcers  assume  the  form  of  the  previous  areas  of 
infiltration  only  in  so  far  as  these  have  not  undergone  involution  by 
simple  absorption.  It  is  worthy  of  mention  that  large  confluent  ulcers 
may  form  in  place  of  the  confluent  patches,  and  that  these  are  most 
frequently  situated  in  the  neighborhood  of  the  ileocecal  ^'alve  and  the 
lowermost  portion  of  the  ileum. 

The  ulcers  resulting  from  the  solitary  follicles  generally  attain  a  size 
from  that  of  a  lentil  or  a  pea  up  to  three-quarters  of  an  inch  in  diameter. 
The  longitudinal  axes  of  the  larger  ulcers  are  not  rarely  directly  trans- 
verse to  the  axis  of  the  intestine.  In  the  rare  cases  in  which  a  number 
of  ulcers  lie  close  together,  even  annular  ulcers  with  subsequent  stenosis 
of  the  large  intestine  may  occur.  Further  extension  of  the  typhoid 
ulcers  after  exfoliation  of  the  sloughs  I  believe,  with  other  observers,  to 
be  uncommon.  On  the  other  hand,  gradual  deepening  of  the  ulceration 
is  probably  not  at  aU  rare,  so  that  ulcers  may  occasionally  give  rise  to 
perforation  at  a  time  when  completion  of  the  process  of  cicatrization 
might  be  expected.  In  the  majority  of  cases,  however,  perforation  does 
not  result  from  such  secondary  extension  of  the  ulcer  in  depth,  but  from 
the  circumstance  that  the  infiltration  from  the  outset  extends  down  to, 
even  involves,  the  serosa,  and  that,  after  exfoliation  of  the  slough,  such 
a  thin,  unresisting  membrane  is  left  that  it  is  not  able  to  withstand  the 
pressure  of  the  intestinal  contents.  There  is  accordingly  a  good  ana- 
tomic basis  for  the  most  frec(uent  occurrence  of  perforative  peritonitis 
at  a  time  when  exfoliation  of  the  sloughs  takes  place,  while  the  secondaiy 


PATHOLOGY.  97 

ulceration  mentioned  explains  in  part  the  occurrence  of  pcrforati<jii  at  a 
much  later  period  of  the  disease. 

In  cases  in  which  death  has  r'csulted  from  intestinal  hemorrhage,  the 
anatomist  is  sometimes  confronted  with  the  most  difficult  and  the  simplest 
technical  problems  side  by  side.  The  excessive,  rapidly  fatal  hemor- 
rhages may  take  place  either  from  large  intestinal  vessels  opened  in  the 
process  of  exfoliation,  and  whose  stumps  are  readily  demonstrable,  or 
mainly  from  capillary  vessels,  so  that  even  on  post-mortem  examination  it 
may  be  difficult  to  demonstrate  the  source  of  the  massive  hemorrhage. 
The  hemorrhages  from  large  vessels  are  observed  especially  when  the 
so-called  indurated  patches  are  exfoliated  as  a  whole  or  in  large  masses. 
The  bleeding  taking  place  from  capillaries  or  from  numerous  minute 
vessels  is  not  rarely  encountered  in  the  earlier  stages  of  necrosis  before 
exfoliation  of  the  slough.  Under  such  circumstances  a  few,  or  many, 
or  almost  all,  of  the  sloughs  are  found  to  be  spongy,  friable,  irregularly 
villous,  suffused  with  blood,  and  blackish  red  or  dark  in  color.  These 
cases  fully  explain  the  frequent  occurrence  of  copious  intestinal  hemor- 
rhage in  the  early  stages  of  typhoid  fever  before  the  close  of  the  second 
week. 

Cicatrization  of  the  typhoid  ulcers  occupies  as  long  a  time,  and  often 
a  longer  time,  than  the  preceding  stages  of  intestinal  alteration.  That 
the  most  extensive  ulcers  with  relation  to  size  and  depth  also  require  the 
longest  time  for  healing  is  a  matter  of  course.  No  doubt,  under  the 
influence  of  general  physical  debility,  the  process  of  healing  may  be 
abnormally  protracted  even  in  the  presence  of  less  profound  ulceration. 
In  this  category  the  condition  described  by  earlier  writers  as  atonic  ulcer- 
ation is  in  part  to  be  included. 

After  cicatrization  has  taken  place  the  affected  areas  are  still  some- 
what depressed,  thinner  than  normal,  smooth,  and  at  first  lighter  m 
color  than  the  surrounding  tissues.  Subsequently  they  become  more  or 
less  markedly  pigmented,  either  diffusely  or  preferably  at  the  margins. 
On  account  of  this  change  in  the  cicatrices,  as  well  as  their  shape  and 
location,  the  previous  occurrence  of  an  attack  of  typhoid  fever  can  often 
be  recognized  in  the  dead  body  after  the  lapse  of  months  or  even  years. 
It  is  a  matter  of  course  that  the  lymphoid  structures  at  the  sites  of 
previous  infiltration  and  ulceration  are  permanently  destroyed.  It  is  a 
matter  of  discussion  whether  intestinal  villi  are  regenerated  over  the 
cicatrices ;  Rokitansky,  Klebs,  and  Birch-Hirschfeld  support  this  view, 
and  as  the  result  of  a  considerable  anatomic  observation  I  can  agree  with 
them  as  to  its  occurrence.  In  general,  examination  of  a  considerable 
number    of  bodies    dead    of    typhoid    fever    will    disclose    the    widest 


98  TYPHOID  FEVER. 

variations  with  regard  to  the  iiuniher,  size,  depth,  and  distribution  of  the 
typhoid  ulcers  in  the  different  portions  of  the  intestines.  To  what  extent 
individual  conditions,  or  tlie  severity  or  mikhiess  of  the  infection  oper- 
ate, cannot  readil}'  be  stated,  as  no  explanation  has  as  yet  been  forth- 
coming for  the  fact  that  the  intensity  of  the  intestinal  lesions  varies  much 
during  different  epidemics.  .Vge  and  sex  appear  clearly  to  determine 
differences.  In  children  the  extent  of  the  medullar}'  sAvelling,  both  of 
Payer's  patches  and  of  the  solitary  follicles,  is  on  the  whole  not  so  great 
as  in  adults.  The  sloughing  also  is  generally  not  so  marked  as  in  the 
latter,  and  this  circumstance  explains  the  greater  rarity  of  intestmal 
hemorrhages  and  perforative  peritonitis  in  childhood.  Undoubtedly,  also, 
involution  of  the  medullary  swelling  by  absorption  is  more  conspicuous 
in  children. 

With  regard  to  the  number  of  infiltrated  Peyer's  patches  in  the  indi- 
vidual case,  some  intestines  are  observed  in  which  not  more  than  3  to  5 
altogether  are  affected.  In  contrast  with  these  cases  are  others  in  which 
scarcely  a  single  patch  in  the  -lower  two-thirds  of  the  ileum  escapes  ;  in 
which  the  neighborhood  of  the  ileocecal  valve  is  almost  continuously  infil- 
trated and  is  thereby  converted  into  one  large  ulcerative  surface.  Not  rarely 
the  vermiform  appendix,  with  its  follicular  apparatus,  is  greatly  involved  in 
the  morbid  process,  and  it  may  occasionally  be  the  seat  of  perforation.  I 
have  observed  as  many  as  36  diseased  patches  in  a  single  body,  and  I  know 
that  other  writers  have  spoken  of  a  still  larger  number.  A  moderate  number 
of  intestinal  ulcers  is  far  more  common,  however,  than  a  very  large  number. 
In  a  study  of  304  autopsies  that  I  made  in  Hamburg  from  the  end  of  1885  to 
1887  with  I'elation  to  the  number  of  ulcers,  in  208  cases  the  specific  intes- 
tinal lesions  were  discrete  and  in  greater  or  less  number.  With  reference 
to  the  localization  of  the  ulcers,  the  notes  of  577  autopsies  at  the  Hamburg 
and  Leipsic  hospitals  are  available.  There  was  involved  :  the  cecum  in  510 
cases,  88.39  per  cent. ;  the  cecum  (often  together  with  the  vermiform  appen- 
dix) in  247  cases,  42.81  per  cent. ;  the  colon  in  184  cases,  31.89  per  cent. ; 
the  jejunum  in  41  cases,  7.10  per  cent.  ;  the  rectum  in  12  cases,  2.08  per  cent. 

Just  as  variations  occur  in  the  number  and  the  intensity  of  the  intestinal 
ulcers  in  different  localities  and  epidemics,  so  are  variations  in  localization 
to  be  observed  also.  It  is  interesting,  for  instance,  that  Hoffmann,  in  the 
epidemic  at  Basle,  observed  involvement  of  the  large  intestine  in  40.3  per 
cent,  of  cases,  Griessinger  at  Zurich  in  40  per  cent.,  while  in  Tubingen  this 
localization  was  observed  in  24  per  cent.  The  most  common  combination 
in  the  seat  of  the  intestinal  lesion  is  apparently  the  ileum,  the  ileocecal  valve, 
and  the  cecum  ;  with  this  is  frequently  associated  involvement  of  the  first 
portion  of  the  colon.  Less  common  than  this  combination  is  involvement 
of  the  ileum  alone,  or  of  this  and  the  lower  half  of  the  jejunum  ;  and  still 
less  common  is  involvement  of  the  cecum  and  the  colon  alone,  or  of  the 
lowermost  portion  of  the  large  intestine  alone  ;  while  exclusive  involvement 
of  the  descending  colon  down  into  the  rectum  is  probably  least  common. 
In  the  uppermost  portions  of  the  jejunum,  and  especially  in  the  duodenum, 
I  have,  together  with  most  observers,  never  found  any  specific  ulceration. 
It  should,  however,  be  mentioned  that  Hamernyk  observed  such  a  condition. 

In  the  same  number  of  577  autopsies  I  found  the  frequency  of  intestinal 


PATHOLOGY.  99 

perforation  and  consecutive  peritonitis  to  be  1.3  per  cent.  These  figures  are 
almost  identical  with  those  obtained  by  Murchison  from  a  collection  of  435 
autopsies  from  various  English  and  French  hospitals,  namely,  13.8  per  cent. 
The  statistics  of  Murchison,  as  well  as  my  own,  are  compiled  from  a  long 
series  of  years,  and  are  thereby  free  from  accidents  due  to  the  character  of 
individual  epidemics.  How  great  variations  may  occur  in  individual  epidem- 
ics is  shown  by  the  observations  of  Hoffmann  at  Basle,  who  found  perforation 
in  only  20  of  250  autopsies — 8  per  cent.  The  seat  of  the  perforation  of  the 
bowel  corresponds  wdth  regard  to  its  frequency  in  general  with  that  of  the 
localization  of  the  ulcers.  Of  64  perforations  that  I  have  studied  in  tliis 
connection,  there  was  involved :  the  upper  portion  of  the  ileum  in  5  cases ; 
the  lower  portion  of  the  ileum  in  39  ;  the  neighborhood  of  the  ileocecal 
valve  in  7  ;  the  vermiform  appendix  in  1  ;  the  colon  in  11 ;  the  rectum  in  1. 

Having  considered  the  specific  alterations  in  the  mucous  membrane, 
the  condition  of  those  portions  of  the  large  and  the  small  intestine  that 
are  not  involved  in  the  processes  of  infiltration  and  ulceration  may  now  be 
discussed.  Upon  this  point  the  anatomic  observations  are  not  so  system- 
atic and  extensive  as  would  be  desirable  from  the  clinical  point  of  view. 
Generally,  references  are  found  only  to  the  character  of  the  mucous 
membrane  in  the  immediate  vicinity  of  the  intestinal  infiltration  and 
ulceration,  and  especially  those  alterations  are  mentioned  that  are  most 
intimately  related  to  those  processes.  As,  however,  the  "intestinal 
symptoms"  in  cases  of  typhoid  fever — that  is,  diarrhea,  meteorism, 
etc. — undoubtedly  do  not  at  any  stage  of  the  disease  stand  in  direct 
relation  to  the  intensity  and  extent  of  the  specific  lesions,  they  must  be, 
at  least  in  part,  explicable  from  the  condition  of  the  remainder  of  the 
intestinal  mucous  membrane.  Doubtless,  it  would  be  found  upon 
further  investigation  that  extensive  catarrhal  alterations,  particularly 
in  the  first  weeks,  exert  a  determining  influence. 

Still  another  question  obtrudes  itself,  not  alone  from  the  theoretic, 
but  also  from  the  practical  standpoint,  namely,  Can  typhoid  fever — that 
is,  the  specific  infectious  disease  induced  by  the  bacillus  of  Eberth — 
exist  also  in  the  absence  of  specific  intestinal  lesions  ?  Even  the  patho- 
logic anatomist,  who  from  the  rigidly  objective  standpoint  of  the  results 
of  post-mortem  examination  might  be  disposed  to  answer  this  question 
in  the  negative,  may  hesitate,  with  a  knowledge  of  cases  presenting  such 
slight  ulcers  in  such  small  number  as  have  been  mentioned.  In  the 
same  way  that  diphtheria  may  be  unattended  with  the  formation  of 
membrane,  and  acute  exanthemata  without  characteristic  cutaneous  erup- 
tion, so  the  follicular  apparatus  of  the  intestine  may  certainly,  though 
with  extreme  rarity,  be  involved  in  minimal  degree  in  cases  of  t^^hoid 
fever.  Almost  every  experienced  clinician  will  recall  cases  in  this  con- 
nection, in  which,  after  most  careful  consideration  of  all  of  the  circum- 


100  TYPHOID  FEVER. 

stances,  typhoid  fever  had  been  diagnosed,  but  upon  po.st-mortem  exam- 
ination only  the  oenoral  aj)pearauees  of  a  profound  infectious  disease 
M'ithout  specific  locahzation  were  found.  Unfortunately,  such  cases 
were  formerly  not  examined  bacteriologiailly.  Pnjof  still  seems  to 
be  wanting  that  typhoid  fever  can  occur  with  no  lesion  whatever 
in  the  gastro-intestinal  tract  during  any  stage  of  the  disease.  This 
]iossibility,  however,  must  always  be  borne  in  mind,  and  several 
authentic  cases  have  been  reported  where  lesions  could  not  be  found 
at  auto})sy. 

The  changes  in  the  mesenteric  glands  stand  in  most  inti- 
mate relation  to  those  of  the  intestine.  They  are  as  constantly  enlarged 
as  the  lymphatic  structures  of  the  intestine,  and  like  them  exhibit  the 
characters  of  medullary  infiltration.  In  general  also  the  localization  of 
the  process  in  the  glands  corresponds  with  that  customary  for  the  intes- 
tinal lesion,  so  that  the  glands  in  the  lower  part  of  the  ileum,  the  cecum, 
and  the  adjacent  parts  of  the  colon  are,  on  the  whole,  involved  most  fre- 
quently and  in  greatest  degree ;  while  those  in  the  uppermost  part  of 
the  small  intestine  and  the  lowermost  part  of  the  large  intestine  more 
frequently  remain  wholly  free  or  are  but  slightly  involved.  This  corre- 
spondence will  naturally  not  be  found  complete  if  large  numbers  of 
cases  are  studied.  Under  exceptional  circumstances  profoundly  involved 
portions  of  intestine  may  exhibit  slight  glandular  involvement,  while,  on 
the  other  hand,  a  slightly  developed  intestinal  lesion  is  sometimes  asso- 
ciated with  disproportionate  glandular  hypeiplasia. 

The  enlargement  of  the  glands  almost  always  extends  far  beyond 
the  narrow  zone  of  those  most  clearly  related  to  the  intestine.  Gener- 
ally, those  of  the  stomach  and  the  portal  fissure,  as  well  as  the  retroperi- 
toneal and  the  bronchial  glands,  are  involved.  The  changes  may  extend 
even  still  further  to  the  lymph-glands  m  the  vicinity  of  the  mouth,  tlie 
larynx,  and  the  deeper  structures  of  the  fauces,  as  well  as  to  those  of 
the  neck  and  the  inguinal  glands. 

The  enlargement  of  the  mesenteric  glands  does  not  begin  much  later 
than  the  infiltration  of  the  lymphatic  structures  of  the  intestine.  The 
glands  become  prominent  as  early  as  the  commencement  of  the  second 
week,  and  attain  their  greatest  size  at  the  height  of  the  disease.  They 
are  then  generally  from  the  size  of  a  pea  to  that  of  a  walnut,  or  even  as 
large  as  an  egg,  tensely  elastic,  from  grayish  red  to  bluish  red  in  color, 
globular,  and  with  a  smooth  or  somewhat  nodular  surface.  On  section 
the  projecting  glandular  structure  is  more  markedly  reddened  in  the 
cortical  than  in  the  medullary  portions,  the  latter  at  times  presenting  a 
grayish  red,  and  in  the  center  even  a  yellowish  red,  appearance.     On 


PATHOLOGY.  101 

microscopic  examination  the  process  is  found  to  be  similar  to  that  seen 
in  Peyer's  patches  and  the  intestinal   follicles. 

The  involution  of  the  glands  keeps  pace  with  that  of  the  intestinal 
lesion.  The  swelling  grows  progressively  less,  the  color  becomes  paler 
from  the  center  toward  the  ])eriphery,  and  the  glands  may  thus,  sinij)ly 
through  absorption,  return  to  their  normal  size.  This  mode  of  involu- 
tion is,  no  doubt,  the  more  common  and  prevalent  one.  Not  rarely, 
however,  it  is  preceded  by  a  process  of  softening  in  the  glands.  This 
may  be  present  in  small  single  or  multiple  areas  in  various  parts  of 
the  gland.  The  softened  mass  may  then  undergo  absorption  directly. 
Less  commonly  larger  portions  of  the  gland  or  even  the  entire  gland 
undergoes  softening,  and  involution  will  then  be  much  more  difficult. 
Under  the  most  favorable  circumstances  there  may  be  gradual  inspissa- 
tion,  terminating  in  calcification  ;  occasionally,  however,  perforation  and 
partial  or  even  general  peritonitis  may  result. 

I,iver  and  Biliary  Passages.— It  is  remarkable  that  the  best 
observers  make  directly  contradictory  statements  with  regard  to  the 
condition  of  the  liver  in  the  typhoid  cadaver.  While  some  describe 
the  organ  as  intact  or  but  little  changed,  others  describe  quite  constant 
alterations  in  its  structure,  discernible  even  macroscopically.  These 
contradictions  are  dependent  prmcipally  upon  the  fact  that  the  structure 
of  the  liver  exhibits  alterations  of  varying  distmctness  at  different  stages 
of  the  disease,  but  that  these  are  at  no  time  likely  to  give  rise  to  consid- 
erable, constantly  recurrmg  changes  in  volume  or  shape.  While  the 
liver  appears  hyperemic,  firm,  and  somewhat  enlarged  durmg  the  early 
febrile  period,  it  becomes  flabbier  and  lighter  in  color  at  the  height  of 
the  disease.  The  condition  represents  the  commencement  of  parenchy- 
matous changes,  the  progress  of  which  keeps  pace  with  those  of  the 
disease  in  general. 

In  the  middle  and  toward  the  end  of  the  second  week  the  flabby, 
somewhat  friable  structure  of  the  liver  presents  upon  section  a  peculiar 
pale,  grayish-brown  appearance.  The  outlme  of  the  lobules,  which 
previously  could  be  seen  distmctly  from  the  surface,  now  appears 
blurred  upon  section,  and  at  times,  and  especially  in  some  parts,  entirely 
obliterated.  In  not  a  few  cases  the  liver  on  section  presents  a  vari- 
able appearance :  in  some  areas  of  greater  or  less  extent  marked 
discoloration  with  a  yellowish  tint,  m  others  better  preservation 
of  outlme  and  of  color,  which  more  nearly  approaches  the  nomial. 
This  appearance  shows  that  the  parenchymatous  degeneration  is  not 
rarely  developed  m  different  degree  in  different  parts  of  the  same 
organ. 


102  TYPHOID  FEVER. 

Microscopic  examination  t)f  the  tissue  of  the  liver  discloses,  in 
correspondence  with  the  results  of  macroscopic  examination  almost 
imexceptionally  in  the  febrile  stat2;c,  more  or  less  advanced  alterations  in 
the  liver-cells.  These  ap})ear  at  iirst  albuminous  and  fatty,  granular 
and  turbid ;  and  they  then  become  swollen  and  filled  progressively  witli 
large  and  small  granules  and  fat-drops,  and  finally  break  up  into 
detritus.  The  degenerative  process  generally  begins  at  the  periphery 
of  the  liver-lobule,  and  rarely  attains  the  same  degree  at  the  center  even 
in  its  further  j)r()gress.  ^Vt  first  the  granular  and  turbid  cells  can  be 
cleared  up  by  addition  of  acetic  acid  ;  but  subsequently,  if  progressive 
fat-infiltration  takes  the  place  of  albuminous  granulation,  this  will  be 
possible  in  but  slight  degree,  if  at  all.  In  cases  of  especially  severe 
onset  and  long  duration  the  parenchymatous  degeneration  and  the  disin- 
tegration of  the  liver-tissue  attain  so  marked  a  degree  that  the  organ 
becomes  diminished  in  size,  flabby,  and  pale  grayish-yellow  in  color,  and 
is  thus,  suggestive  of  the  condition  observed  in  acute  yellow  atrophy  of 
the  liver. 

Wagner  ^  described  as  a  specific  feature  of  typhoid  fever  the  presence 
of  small,  generally  interacinous,  grayish-white  nodules  in  the  liver- 
tissue,  which  he  described  as  accumulations  of  lymphoid  cells,  and 
considered  analogous  to  the  lymphoid  hyperplasia  of  the  intestinal 
follicles  and  the  similarly  constituted  nodules  of  the  peritoneum. 
Hoffmann  obser\^ed  these  formations  in  38  of  250  cases,  but  he 
believed  them  to  be  actually  still  more  common.  Later  examinations, 
however,  have  not  shown  them  to  be  peculiar  to  typhoid  fever,  as  they 
have  been  observed  in  other  infectious  diseases  also.  Reed,^  from  a 
study  of  these  so-called  lymphoid  nodules,  concluded  that  they  are  not 
composed  of  lymphoid  cells,  but  that  in  the  earlier  stages  the  abundant 
nuclei  present  arise  in  lesser  part  from  the  disintegration  of  nuclei  of 
the  liver-cells,  and  in  greater  part  are  those  of  polymorphonuclear  leu- 
kocytes which  have  wandered  into  the  necrotic  area.  He  thought  the 
necrosis  was  probably  not  due  to  the  immediate  presence  of  the  typhoid- 
bacillus,  but  probably  due  to  the  action  of  a  circulating  toxin.  Mallory  * 
thinks  there  are  two  varieties  of  the  focal  lesions  :  one  consists  in  the 
formation  of  phagocytic  cells  in  the  lymph-spaces  and  vessels  around 
the  portal  vessels,  and  is  due  to  the  action  of  the  toxin  ;  the  other  is 
due  to  the  obstruction  of  liver-capillaries  l)y  phagocytic  cells,  derived 
chiefly  by  embolism  through  the  portal  circulation  of  cells  originating 
from  the  endothelium  of  the  blood-vessels  of  the  intestine  and  spleen. 

1  Arch.  d.  Heilk.,  1860.  '  Johns  Hopkins  Hosp.  Rep.,  vol.  v. 

'  Loc.  cit. 


PATHOLOGY.  103 

The  liver-cells  lying  between  the  occluded  capillaries  then  undergo 
necrosis  and  disappear.  Reed  was  able  to  show  no  intimate  relation 
between  the  typhoid-bacillus  and  these  areas.  The  character  of 
the  bile  corresponds  with  the  extensive  changes  in  the  parenchyma  of 
the  liver ;  and  this  secretion,  in  contradistinction  from  that  in  other 
acute  infectious  diseases,  is  generally  light  in  color  and  limpid.  Its 
specific  gravity  is  between  1010  and  1016,  as  compared  with  from 
1026  to  1030  under  ordinary  conditions  (Brouardel).  Much  less 
commonly,  as  is  the  rule,  for  instance,  in  typhus  fever,  it  is  viscid 
and  dark. 

Great  interest  has  recently  been  attracted  to  the  anatomic  alterations 
in  the  large  biliary  passages.  Ulcerative  and  even  diphtheric  processes 
in  the  wall  of  the  gall-bladder  and  the  large  biliary  passages,  with 
secondary  destruction  and  abscesses  in  the  liver  or  perforative  peritonitis, 
had  previously  been  described  as  rare  occurrences  (Andral,  Louis, 
Jenner,  Leudet,  Rokitansky,  and  others).  After  Gilbert  and  Girode  ^ 
had  first  demonstrated  typhoid-bacilli  in  the  gall-bladder,  Chiari  ^  showed 
that  the  necrotic  processes  in  the  biliary  passages  were  in  general  due 
principally  to  these  organisms,  and  that  they  could  be  regularly  found  in 
the  gall-bladder.  He  was  able  to  demonstrate  the  bacilli  in  20  of  22 
autopsies.  Similar  observations  were  made  by  Birch-Hi rschfeld,^  who,  in 
agreement  with  Chiari,  concludes  that  the  gall-bladder  probably  consti- 
tutes a  common  and  important  source  for  reinfection. 

In  addition  to  direct  extension  of  the  ulcerative  process  in  the  large 
biliary  passages  to  the  surrounding  hepatic  parenchyma,  abscess  of  the 
liver  may  occur  in  cases  of  typhoid  fever  under  other  conditions  also, 
as  part  manifestation  of  general  pyemia  and  as  a  result  of  septic  throm- 
bosis of  branches  of  the  portal  vein,  which  is  usually  dependent  upon 
ulcerative  and  suppurative  conditions  of  the  intestine,  especially  peri- 
typhlitis and  paratyphlitis.  For  a  more  detailed  description  of  these 
conditions  reference  may  be  made  to  the  clinical  part  of  this  work,  in 
which  my  own  clinical  experiences  and  those  of  other  observers  are 
recorded  together  with  the  anatomic. 

Changes  in  the  pancreas  are  mentioned  by  few  writers  on 
account  of  their  relatively  slight  importance.  Among  older  writers, 
Roderer  and  Wagler,*  Louis,  and  Murchison  refer  to  the  occasional 
occurrence  of  induration,  enlargement,  and  hyperemia  of  the  organ  in 

^  Sem.  med.,  No.  58,  1890,  and  Oompt-rend.  de  la  soc.  biol.,  1891,  No.  11. 

^  Prag.  med.   Woch.,  1893,  No.  22. 

^  Lehrbuch  d.  path.  Anat.,  4  Aufl.,  Bd.  ii.,  S.  694. 

*  De  Morbo  7nucoso,  Gottingen,  1762. 


104  TYPHOID  FEVER. 

the  bodies  of  those  dead  of  typhoid  fever.  H(^ffniann  ^  was  the  first  to 
devote  attention  particularly  to  the  pancreas,  and  he  ob.-^erved  changes 
similar  to  those  in  the  salivary  glands  recurring  with  considerable 
regularity.  In  the  first  period  of  typhoid  fever  the  gland  is  generally 
enlarged,  hard,  grayish  red,  and  even  more  deeply  red  in  color.  On 
microscopic  examination  there  will  be  found  dilatation  and  overfilling 
of  the  smaller  and  smallest  vessels,  with  serous  infiltration  of  the 
adjacent,  still-intact  parenchyma.  In  the  later  stages  the  pancreas, 
which  at  first  was  enlarged,  becomes  discolored  and  presents  a  grayish- 
yellow  or  even  grayish-brown  appearance.  Toward  the  end  of  the 
attack  the  pancreas  again  becomes  diminished  in  size,  and  upon  comj)lcte 
recovery  acquires  its  normal  consistence  and  color.  In  the  second  stage 
the  increase  in  the  size  of  the  gland  appears  to  be  dependent  upon 
enlargement,  multiplication,  and  active  division  of  the  cells,  and  the 
discoloration  upon  albuminous-fatty  degeneration. 

HEART  AND  VASCULAR  SYSTEM. 

Little  is  known  concerning  tlie  anatomic  condition  of  the  myocardium 
in  the  initial  and  the  first  febrile  stage  on  account  of  the  rarity  of  death 
at  this  period.  Generally,  the  size,  consistency,  and  color  of  the  myocar- 
dium are  described  as  normal,  although,  even  in  early  stages,  increased 
friability,  flabbiness,  dilatation,  especially  of  the  right  half  of  the  heart, 
and  discoloration  of  the  heart-muscle  have  often  been  mentioned.  These 
conditions  almost  constantly  occur  in  the  height  of  the  disease  and  the 
subsequent  course  of  the  febrile  stage.  This  was  known  already  to 
earlier  observers.  Laennec  ^  speaks  of  "  softening  "  of  the  heart,  with 
violet  or  brownish-yellow  discoloration.  Subsequently,  Louis,  Stokes, 
and  Rokitansky  gave  descriptions  of  the  macroscopic  changes  in  the 
heart-muscle  at  the  height  of  the  attack  of  typh(nd  fever  that  at 
the  present  day  are  still  considered  models.  Naturally,  these  observers 
were  unable  to  advance  materially  the  clinical  comprehension  of  these 
conditions.  It  is  only  within  recent  times  that  a  clear  insight  into 
the  nature  of  the  functional  disturbances  of  the  heart  in  cases  of 
typhoid  fe\'er  has  been  obtained  as  the  result  of  a  large  number  of 
valuable  stuches  of  the  histologic  changes  in  the  myocardium.  At 
first,  under  the  leadership  of  Virchow,^  a  number  of  parenchymatous 
changes   and   consecutive   regenerative   processes  were  established   by 

>  Loc.  cif.^  p.  191  et  seg. 

^  Th-aite  de  V auscultation  inediate,  second  edition,  1826. 

^  See  the  famous  article  upon  parenchymatous  inflammation  in  Virchoiv's  Archiv, 
Bd.  iv. 


PATHOLOGY.  105 

B5ttcher,i  Zenker,^  Waldeycr,''  Hoffmann,'  Hayem/  and  others,  to  which 
was  subsequently  added  a  knowledge  of  interstitial  inflammatory  j)roc- 
esses,  first  indicated  by  Hayera/  and  recently  materially  advanced   by 

RombergJ 

Amono-  the  parenchymatous  alterations,  consideration  should  be  given 
especially  to  albuminoid  granulation.  Less  common,  especially  as  com- 
pared with  other  infectious  diseases,  as,  for  instance,  diphtheria  (Rom- 
berg), fatty,  and  in  isolated  cases  hyaline,  waxy  degeneration  have  been 
observed.  In  addition,  there  is  remarkable  enlargement  of  the  nuclei 
in  the  form  of  elongation  or  distention  almost  constantly,  at  least  in 
adults,  with  abundant  deposition  of  pigment  in  their  vicinity  (Rom- 
berg). The  muscle-fibers  themselves  often  exhibit  a  sort  of  vacuolation 
and  a  peculiar  change  in  the  form  of  numerous  transverse  tears — myo- 
cardite  segmentaire  (Renault) — which,  however,  von  Recklinghausen, 
Zenker,  and  recently  also  Romberg  are  disposed  to  consider  as  agonal 
products. 

The  parenchymatous  alterations  have  been  found  in  hearts  presenting 
macroscopically  little  change,  as  well  as  in  those  that  from  their  external 
appearances  had  to  be  designated  as  friable,  brittle,  discolored,  and 
dilated.  They  mvolve  both  the  left  and  the  right  side  of  the  heart,  and 
appear  to  be  more  extensive  and  more  constant  in  the  outer  and  inner 
layers  of  the  myocardium  than  in  the  middle  layers,  which,  however, 
also  present  considerable  alteration  at  times  (Romberg).  Not  much  of  a 
definite  nature  has  as  yet  been  determined  with  regard  to  the  relations 
between  the  parenchymatous  changes  and  the  clinical  symptoms. 

Fuller  knowledge  exists  with  regard  to  interstitial  myocarditis,  which 
exhibits  microscopically  the  characters  of  true  interstitial  inflanmaation  : 
round-cell  infiltration  between  the  larger  muscle-bundles,  which  extend 
from  this  point  between  the  finer  bundles  ;  capillars^  ectasis,  the  vessels 
often  being  greatly  distended  with  white  blood-corpuscles.  In  addition, 
a  peculiar  affection  of  the  smaller  and  smallest  arteries  of  the  myo- 
cardium has  been  described  by  French  observers  (Hayem,  Martin) 
as  important  and  frequent,  and  been  designated  obliterating  endarter- 
itis. Hayem  claims  to  have  observed  this  especially  in  a  number  of 
cases  ua  which  sudden  death  occurred  in  collapse.     He  describes  the 

1  See  the  famous  article  upon  parenchymatous  inflammation  in  Virchmrs  Archiv, 
Bd.  xiii. 

^  Ueber  die  Verdnderungen  der  willkurlichen  Muskeln  in  Typhus  abdominalis, 
Leipsic,  1864. 

*  Virchow's  Archiv,  Bd.  xxxiv.  *  Loc.  cit. 

5  Arch,  dephys.  norm,  etpathol.,  1870.  ^  Ibid.,  1869. 

'  Arbeit,  a.  d.  med.  Klin.  z.  Leipsic,  1893. 


106  TYPHOID  FEVER. 

affection  as  an  inflammatory  hypoiplasia  of  the  cellular  elements  of 
the  intima  of  the  .smaller  arteries,  which  as  a  result  suffer  considerable 
thickening  of  their  Avails  and  narrowing  of  their  lumen.  liomberg 
has  been  able  to  verify  these  observations  only  in  isolated  instances, 
and  therefore  with,  good  reason  expresses  doubt  as  to  their  frequency 
and  general  signihcance.  So  far  as  is  known,  the  inflammatory  process 
extends  in  such  a  \\i\\  that  both  the  right  and  the  left  sides  of  the 
heart  are  involved,  the  latter  generally  in  greater  degree  and  pref- 
erably at  the  apex  and  the  base.  Romberg  was  able  to  demon- 
strate that  the  myocarditis  frequently  originated  from  similar  inflam- 
matory processes  of  the  (visceral)  pericardium  and  the  endocardium. 
As  clinical  experience  also  shows,  the  interstitial  myocarditis  appears  in 
a  majority  of  cases  to  undergo  complete  involution,  without  leaving  func- 
tional or  anatomic  disturbances  in  the  myocardium.  In  rare  instances 
(von  Leyden,  Romberg)  permanent  fibroid  changes  can  probably  be 
demonstrated.  Whether  abscess  of  the  heart  may  be  a  result  has  not 
been  demonstrated. 

In  contradistinction  from  other  infectious  diseases,  endocarditis, 
especially  that  involving  the  valves  and  terminating  m  valvular  lesions 
of  the  heart,  is  extremely  rare.  Vegetative  or  ulcerative  endocarditis 
also  only  exceptionally  comes  under  observation  (Griessinger,  Lieber- 
meister,  Bouchut).  Several  cases  have  been  reported  in  which  the 
typhoid-bacillus  in  pure  culture  was  isolated  from  the  affected  valve. 
Probably  the  lesion  is  usually  due  to  secondary  infection  with  the 
pyogenic  cocci.  Romberg  has  called  attention  to  focal,  generally  mural, 
endocarditis  beyond  the  limits  of  the  valves,  and  demonstrable  only  on 
microscopic  examination.  It  appears  rarely  to  acquire  considerable 
extent  in  cases  of  typhoid  fever,  and  to  acquire  clinical  significance  only 
under  special  conditions.^  With  a  certain  degree  of  preference  it 
extends  deeply  by  way  of  the  vessels  or  the  interstices  between  the 
muscles,  thus  giving  rise  to  a  direct  transition  into  myocarditis.  Accord- 
ing to  Romberg,  more  or  less  extensive  round-cell  infiltration,  the  source 
for  which  consists  in  a  dense  network  of  small  veins  and  capillaries  in 
this  situation,  is  present  more  frequently  in  the  depth  of  the  visceral 
layer  of  the  pericardium,  at  the  junction  between  it  and  the  superfi- 
cial layers  of  the  myocardium.  This  inflammatory  process  also  extends 
preferably  deeply  into  the  myocardium  and  rarely  toward  the  surface  of 
the  pericardium.  Gross  forms  of  pericarditis,  with  fibrinous  deposits 
or  fluid  inflammatory  effusion,  appreciable  macroscopically  and  giving 
rise  to  clinical  manifestations,  is,  accordingly,  quite  exceptional.  In 
1  See  the  appropriate  section  in  the  clinical  part. 


I 


PATHOLOGY.  107 

isolated  instances,  it  is  true,  I  have  found  fibrinous  deposits  upon  the 
pericardium,  in  association  with  complicating  croupous  pneumonia,  and 
in  a  few  instances  purulent  pericarditis  as  a  part  manifestation  of  com- 
plicating sepsis. 

The  changes  in  the  large  vessels,  although  responsible  for  a  number 
of  not  uncommon  clinical  manifestations,  have  as  yet  not  been  thor- 
oughly studied.  The  veins  are  more  frequently  affected  than  the  arte- 
ries. Typhoid  phlebitis  appears  to  be  the  usual  cause  for  phlegmasia 
alba  dolens  during  convalescence  from  typhoid  fever,  while  a  special 
variety  of  arteritis  is  probably  responsible  for  spontaneous  gangrene  of 
the  extremities,  which,  fortunately,  is  rare.  The  anatomic  alterations 
that  take  place  are  considered  in  detail  in  a  later  section,  together  with 
the  clinical  manifestations.^  In  the  same  section  will  be  found  a  com- 
plete description  of  the  state  of  the  blood  in  cases  of  typhoid  fever. 

THE  SPLEEN, 

In  its  behavior  the  spleen  is  comparable  essentially  to  Peyer's 
patches  and  the  follicles  of  the  intestine  and  the  mesenteric  glands. 
Like  these  it  is  almost  always  swollen  at  the  commencement  and  at  the 
height  of  the  disease.  In  any  event,  absence  of  enlargement  of  the 
spleen  at  this  period  in  youthful  and  older  individuals  under  the  age  of 
forty-five  years  is  most  exceptional.  Apart  from  a  few  cases  inexplica- 
ble in  this  connection,  it  appears  to  be  wanting  only  after  antecedent 
disease  of  the  organ,  giving  rise  to  considerable  and  universal  thickening 
of  its  capsule  or  firm  hyperplasia  of  its  stroma  (Hoffmann),  and  thereby 
permanently  destroying  its  distensibility.^  In  elderly  persons  senile 
atrophy  of  the  spleen  at  times  prevents  the  occurrence  of  tumefaction. 
The  enlargement  of  the  spleen  is  most  marked  at  the  height  of  the  febrile 
stage,  while  at  the  commencement  of  this  stage  and  in  individuals  dying 
in  the  stage  of  defervescence  its  volume  is  not  markedly  increased. 
The  enlargement  of  the  spleen  in  typhoid  fever  is  in  general  not  ver}^ 
considerable.  When  the  swelling  is  at  its  greatest,  the  organ  may  be 
twice  or  thrice  its  usual  size.  A  greater  degree  of  enlargement  is 
extremely  rare,  and  even  enlargement  to  thrice  the  normal  is  dispro- 
portionately much  less  common  than  to  one  and  a  half  times  or  t^^dce 
the  normal,  as  will  be  seen  from  the  following  table  of  Hoffmann, 
givmg  the  measurements  of  the  spleen  in  118  fatal  cases  of  tj^phoid 
fever : 

1  See  the  clinical  f5ection. 

*  Consult  particulars  as  to  cause,  nature,  and  temporal  relations  of  enlargement  of 
the  spleen  in  the  section  on  Analysis  of  the  Individual  Symptoms. 


108 


TYPHOID  FEVER. 


Duration  of  the 
Disease. 

o 

(U  O 

o 

"3 

6 

a3t«  ^ 

52  "3 

si 

as 

S  o 

2  weeks 

3  ^' 

4  " 

5  " 

6  " 

7  " 

8  " 

9  " 

10  " 

11  " 

13  " 

14  " 
16     " 
23     " 

27  " 

28  " 
31      " 

1 

1 
1 

1 

5 
11 

6 
11 

2 

5 

2 

2 

2 

1 

l' 

12 
15 
8 
3 
3 
3 
2 

1 

2 

1 
1 

7 
12 
17 

4 

'1 

1 

1 

4 
4 
4 

5 
3 

l' 

3 
6 
3 

1 

1 

1 

Total    . 

4 

48 

51 

43 

21 

U 

1 

The  cause  of  the  enlargement  of  the  spleen  is  to  be  attributed  to  two 
main  factors — distention  with  blood  and  hyperplasia  of  the  tissue.  If 
opportunity  be  afforded  to  examine  the  spleen  from  the  middle  of  the 
first  to  the  middle  of  the  second  week,  the  organ  appears  smooth  and 
tense,  upon  section  dark  red  in  color,  extremely  bloody,  with  an  indefinite 
outline.  Toward  the  end  of  the  second  and  in  the  third  week  the 
organ,  which  has  become  still  larger,  is  softer,  at  times  dark  brownish 
red,  even  brownish  black  in  color,  and,  while  previously  the  loiife-blade 
d^a^vn  over  the  cut  surface  removed  little,  it  now  readily  takes  with  it 
in  considerable  amount  the  mushy,  diffluent  splenic  pulp.  With  the 
advent  of  defer\^escence  the  spleen  undergoes  relatively  rajjid  diminu- 
tion in  size.  The  previously  distended  capsule  becomes  relaxed  and 
wrinkled,  and  the  hyperemia  subsides,  while  the  hypei'plasia,  especially 
that  of  the  stroma,  persists.  These  changes  result  in  a  lighter  color, 
the  transverse  section  presenting  a  yellowish-red  appearance,  at  times 
yellowish-brown  from  the  presence  of  pigment,  while  the  outline  of  the 
stroma  becomes  again  more  distinct  and  the  knife  removes  scarcely  any- 
thing from  the  cut  surface.  The  entire  organ  now  acquires  a  peculiar 
tough  consistence. 

Among  other  alterations  in  the  spleen,  infarcts,  which  are  rare  and 
are  dependent  upon  thrombosis  or  embolism  of  the  splenic  arteries,  and 
abscesses,  which  are  still  rarer,  may  be  mentioned.  Not  all  of  the  con- 
ditions that  have  been  described  by  earlier  observers  as  abscesses  are 
to  be  considered  as  such.    Doubtless,  old  discolored  and  softened  infarcts 


PATHOLOGY. 


109 


have  been  included  in  this  description.  The  true  abscesses  of  the  spleen 
also  appear  in  part  to  result  from  infarction  (Jenner,  Ploff'mann,  Leudetj. 
Others  are  a  part  manifestation  of  general  sepsis.  Both  infarcts  and 
abscesses  may  rupture  into  the  abdominal  cavity  and  give  rise  to  general, 
in  more  favorable  cases  circumscribed,  peritonitis.  Some  cases  of  "  spon- 
taneous "  rupture  of  the  excessively  distended  spleen,  filled  with  blood, 
at  the  height  of  an  exceedingly  severe  attack  of  typhoid  fever  are  also 
referred  to  in  the  literature  (Loebl,  Leudet).  Although  such  cases  are 
among  the  rare  exceptions,  and  each  instance  is  to  be  accepted  with 
great  reservation,  they  certainly  cannot  be  entirely  ignored  in  view  of 
the  extreme  tension,  softness,  and  attenuation  of  the  capsule,  such  as 
occur  in  that  organ  in  severe  and  protracted  cases. 

The  finer  alterations  in  the  spleen,  which  have  been  already  described 
by  numerous  observers,  especially  Billroth  ^  and  Birch-Hu-schfeld,^  are 
related,  as  is  known  at  the  present  day,  most  intimately  to  the  invasion 
of  the  organ  by  the  typhoid-bacilli, 
which  during  the  febrile  stage  of 
the  disease  are  quite  constantly 
present  in  this  organ  in  abundance 
and  in  peculiar  arrangement.  They 
are  distributed  throughout  the  organ 
in  the  form  of  innumerable  irregu- 
larly arranged  groups,  in  which  the 
bacilli  lie  so  close  together  that  in 
stained  sections  they  appear  as  dark, 
opaque  spots,  at  the  periphery  of 
which  individual  bacilli  may  be 
recognizable  (Fig.   7). 

In  other  respects  the  histologic 
alterations  are  in  general  scarcely 
different  from  those  of  the  acute 
infectious  splenic  tumor :  In  the  early  stage,  especially  hyperemia, 
particularly  with  overdistention  of  the  cavernous  veins  of  the  pulp, 
and  with  further  advance  in  the  morbid  process,  most  active  hyper- 
plasia of  the  cellular  elements  of  the  spleen  and  of  the  stroma,  together 
with  the  appearance  of  those  large  cells  (phagocytes)  containing  red 
blood-corpuscles,  which  recently  have  acquired  such  great  theoretic 
importance.      The  significance  of  inflammatory  changes  in  the  smaller 


Fig.  7. — Section  of  the  spleen,  showing 
groups  of  typhoid-baciUi. 


1  Virchow's  Archiv,  Bd.  xxiii. 

'^  Arch.   d.   Heilk.,  Bd.   xiii.  ;  and   Tagebl.  der  4'^  Versammlung  deutscher  Naiur- 
forscher  u.  Aerzte. 


110  TYPHOID  FEVER. 

arteries  of  the  spleeu,  to  which  French  investigators  especially  have 
directed  attention  (Siredey),  has  not  as  yet  been  sufficiently  established. 

ALTERATIONS  IN  THE  URINARY  ORGANS. 

Apart  from  tliC  rare  cases  in  which  death  takes  place  in  the  early 
stages  of  typhoid  fever,  the  kidneys  generally  exhibit  more  or  less 
marked  alterations  appreciable  to  the  naked  eye,  which  are  comparable 
to  those  in  other  parenchymatous  organs,  especially  the  liver.  At  the 
beginning  or  the  middle  of  the  second  week  the  kidneys  are  usually  still 
of  normal  size  or  but  slightly  enlarged,  usually  greatly  reddened  upon 
their  external  aspect,  upon  section  markedly  hy])eremic,  so  that  the 
medullary  structure  often  is  dark  bluish  red  in  color,  the  cortex  some- 
what lighter,  from  red  to  grayish  red.  AYith  the  progress  of  the  disease 
the  organ  generally  undergoes  further  enlargement.  It  becomes  firmer, 
its  color  lighter,  and  the  capsule  removable  with  difficulty.  The  cortex 
now  appears  enlarged,  pale  grayish  red,  often  with  a  yello^vish  tint, 
while  the  pyramids  for  a  time  retain  their  dark-red  color,  with  the 
exception  of  the  papillse,  which  soon  acquire  a  yellowish  appearance. 
After  a  long  and  severe  attack  of  fever,  especially  in  protracted  cases, 
the- kidneys  subsequently  become  smaller,  flabbier,  and  often  lighter  in 
color,  in  the  same  way  as  has  been  mentioned  with  regard  to  the  liver. 
The  diminution  in  size  generally  takes  place  at  the  expense  of  the  cortex, 
which  now  appears  smaller,  and  pale  grayish  yellow  in  color,  Avhile  the 
medullary  substance  also  frequently  becomes  somewhat  paler. 

The  alterations  described  are  the  macroscopic  expression  of  the 
beginning  progressive  parenchymatous  degeneration,  eventually  attain- 
ing a  high  grade.  Microscopically  this  is  manifested  by  albuminous- 
fatty  turbidity  of  the  epithelial  cells  of  the  uriniferous  tubules,  which 
soon  undergo  vitreous  swelling,  become  filled  with  smaller  and  larger 
fat-globules,  finally  dismtegrate,  and  thus,  together  with  innumerable 
hyaline  and  granular  tube-casts,  often  occlude  the  uriniferous  tubules  for 
a  considerable  distance.  The  cells  are  then  present  constantly  also  in 
the  cloudy  fluid  that  can  at  this  time  be  expressed  from  the  apices  of  the 
papillfe.  The  parenchymatous  degeneration  almost  always  begins,  as 
can  be  distinguished  with  the  naked  eye,  in  the  cortical  structure,  and 
only  later,  and  often  not  in  equal  degree,  is  the  medullary  structure  also 
involved. 

The  alterations  described  have  been  recognized  for  a  considerable 
time,  at  least  macroscopically,  as  part  manifestations  in  cases  of  typhoid 
fever  of  moderate  and  of  severe  course.     Gregory '  and  Rayer  ^  have 

1  Edinb.  Med.  Jour.,  1831.  '  Maladie.i  des  reins,  1840. 


PATHOLOGY.  Ill 

referred  to  this  condition  in  connection  with  febrile  albuminuria,  and 
Hoffmann  ^  and  E.  Wagner,^  upon  the  basis  of  extensive  statistics,  have 
discussed  it  in  an  exhaustive  manner.  In  rare  cases  the  changes  men- 
tioned do  not  proceed  beyond  this  stage ;  but,  on  the  other  hand,  clini- 
cally well-defined  conditions  of  acute  nephritis  also  occur.  These  may 
appear  early,  in  the  middle  of  the  second,  even  at  tlie  end  of  the  first 
week,  and  they  may  dominate  the  clinical  picture  to  such  a  degree  that 
French  observers  especially  have  felt  justified  in  applying  to  such  cases 
the  designation  nephrotyphoid.^  The  anatomic  picture  of  typhoid  neph- 
ritis is  generally  that  of  acute  parenchymatous  hemorrhagic  inflamma- 
tion, usually  with  subordinate  iaivolvement  of  the  mterstitial  tissue. 

Wagner  *  and  von  Recklinghausen  ^  have  called  attention  to  a  peculiar 
variety  of  nephritis  attended  with  numerous^  miliary,  interstitial,  puru- 
lent foci,  which  in  rare  cases,  as  I  have  myself  observed  in  one  instance, 
may  coalesce  into  abscesses  varying  in  size  from  that  of  a  bean  to  that 
of  ai  walnut.  Von  Recklinghausen  had  already  attributed  this  affection 
to  emboli  of  micrococci.  At  the  present  day  there  is  scarcely  any  doubt 
tliat  the  condition  is  generally  of  septic  origin.  However,  cases  of 
multiple  abscesses  in  the  kidney,  due  to  the  action  of  the  typhoid- 
bacillus,  may  occur,  as  in  the  case  reported  by  Flexner,^  in  which  there 
was  a  typhoid  septicemia  with  focal  abscesses  in  the  kidney,  from  which 
the  typhoid-bacillus  was  isolated  in  pure  culture. 

In  one  case  I  had  the  opportunity  of  examining  the  kidneys  from  a 
man  dead  after  symptoms  of  pure  hemoglobinuria.  The  organs  were  of 
normal  size,  dark  sepia-brown  in  color,  and  unusually  hard.  On  section 
the  cortex  was  dirty  brownish  gray,  the  pyramidal  tissue  dark  brownish 
red,  almost  black.  The  renal  epithelium,  both  in  the  cortex  and  in  the 
medullary  tissue,  was  in  a  state  of  albuminous-fatty  clouding  and  dis- 
integrated, and  the  convoluted  and  straight  uriniferous  tubules  were 
filled  with  masses  of  brownish-red,  glistening  hemoglobin  tube-casts  and 
flakes. 

As  in  the  liver,  Wagner  has  occasionally  demonstrated  in  the  kidney 
also  the  presence  of  small  gray  lymphomatous  nodules,  wliich  develop 
almost  exclusively  in  the  cortical  tissue  in  the  immediate  vicinity  of 
minute  vessels.  Hoffmann  has  observed  them  half  as  frequently  as  in 
the  liver. 

'  Loc.  cit. 

'^  Zienissen's  Handhiirh  der  speciellen  Pathologic^  Bd.  ix.,  3  Aufl.,  1  Th. 
•''  Compare  the  literature  in  the  cliniciil  portion,  Disturbances  on  the  Part  of  the 
Urinary  Organs. 

'  Loc.  cit.  '  Ver/iandl.  d.  p/i)/.sik.-}ned.  Oesellsch.  z.  ]Viirzbu?-g,  1871. 

''Jour,  of  Path,  and  Bact.,  1895,.  vol.  iii. 


112  TYPHOID  FEVER. 

Infarcts  of  the  kidney  arc  observed  rarely,  Hoffmann  having  found 
them  10  times  m  250  autopsies. 

Tlie  alterations  in  the  remainder  of  the  urinary  tract  are  extremely 
uncommon  as  comj)ared  Avitli  those  in  the  kidneys.  I  have  in  a  number 
of  instances  observed  continuous  hemorrhages  of  considerable  amount 
or  numerous  smaller  extravasations  of  blood  in  the  mucous  membrane 
of  the  pelvis  of  the  kidney,  as  they  have  been  described  by  Louis  and 
Rayer.  Purulent  pyelitis,  which  also  is  mentioned  in  the  literature,  I  have 
never  encountered.  The  mucous  membrane  of  the  ureters  is  rarely 
altered,  here  and  there  small  hemorrhages  are  occasionally  seen.  The 
urinary  bladder  likewise  exhibits  more  or  less  extensive  hemorrhage 
into  the  mucous  membrane  only  in  rare  cases.  At  times  these  are 
associated  with  catarrhal  states,  or  even  "diphtheric"  destruction  of 
the  mucous  membrane.  Quite  exceptionally  the  latter  gives  rise  to 
phlegmonous  inflammation  of  the  wall  of  the  bladder,  with  perforation 
and  peritonitis. 

The  urine  of  typhoid  patients  may  contain  very  large  numbers  of 
typhoid-bacilli  without  giving  rise  to  symptoms  or  signs  of  an  associated 
cystitis.  Frequently,  such  urine  contains  a  larger  or  smaller  number  of 
pus-cells,  but  it  is  not  uncommon  for  typhoid  urines  not  so  infected  to 
contain  a  few  pus-cells.  To  the  condition  of  typhoid-bacilli  in  the 
urine  without  associated  cystitis  the  term  "  bacilluria  "  has  been  given. 
This  occurs  in  25  to  35  per  cent,  of  all  cases  of  typhoid  fever.  It  is 
difficult,  however,  to  draw  a  sharp  line  between  the  cases  of  bacilluria 
and  those  of  true  cystitis.  The  presence  of  a  cystitis  at  autopsy  is  a  rare 
occurrence.  It  is  probable,  as  Horton  Smith  ^  suggests,  that  a  bacilluria 
only  gives  rise  to  a  cystitis  when  there  occurs  marked  retention,  or  if 
the  bladder-walls  should  be  damaged  in  any  way.  Young  ^  has  reported 
a  most  interesting  case  of  chronic  cystitis,  due  to  the  typhoid-bacillus, 
persisting  seven  years  after  the  attack  of  fever.  He  has  collected  from 
the  literature  two  other  similar  cases,  ha^'iug,  however,  a  shorter 
duration. 

The  possibility  of  infection  of  the  bladder  from  without  by  intro- 
duction of  the  typhoid-bacillus  on  a  sound  or  a  catheter  has  recently 
been  suggested  by  a  case  reported  by  Brown,^  the  bladder  of  which 
showed  an  acute  inflammation.  Cultures  showed  only  Bacillus  typho- 
sus, and  the  only  apparent  possible  mode  of  infection  was  by  means  of  a 
catheter.     This  case  is  apparently  unique. 

^  The  Typhoid-hacillus  and  Ti^phoid  Fever ^  London,  1900. 

=>  Johns  Hopkins  Hosp.  Rep.,  vol.  viii.  '  Med.  Record,  March  10,  1900. 


PATHOLOGY.  113 

ALTERATIONS  IN   THE  RESPIRATORY  ORGANS. 

The  nasal  cavity  generally  exhibits  the  appearances  of  catarrh  with 
scanty  secretion.  At  times,  especially  when  obstinate  epistaxis  has 
taken  place  during  life,  superficial  erosions  and  bloody  suffusion  of  the 
mucous  membrane  of  the  turbmates  and  the  septum  are  present  in 
places.  Croupous  and  diphtheric  deposits  in  the  nares  are  rare,  and 
almost  always  only  in  association  with  like  processes  upon  the  soft  palate 
and  the  tonsils. 

I^arynx. — Upon  the  mucous  membrane  of  the  larynx  mild 
catarrhal  manifestations  are  among  the  most  fi'cquent  occurrences ;  less 
commonly  they  attain  a  considerable  degree  of  severity.  Even  laryngeal 
ulceration  in  milder  grades  occurs  in  a  fairly  large  proportion  of  the 
severe  cases.  Griessinger  found  such  ulcers  in  26  per  cent,  of  the  fatal 
cases.  The  more  severe  typhoid  alterations  in  the  larynx  are  interesting 
and  important.  Keen  ^  has  collected  and  reviewed  221  cases,  obtained 
from  the  literature  up  to  1898.  These  lesions  generally  arise  from 
superficial  erosions,  which  may  rapidly  penetrate  deeply  and  give 
rise  to  extensive  ulceration,  with  perichondritis  and  destruction  of 
the  cartilage.  The  usual  seat  of  typhoid  ulcers  of  the  larynx  is  the 
posterior  internal  wall  of  this  organ,  whence  they  may  extend  to  the 
posterior  portion  of  the  vocal  bands,  generally  in  the  form  of  superficial 
erosions.  On  the  posterior  walls,  however,  the  ulceration  is  often  deep, 
at  first  attended  with  extensive  edema  of  the  adjacent  parts,  the  mucous 
membrane  of  the  arytenoid  cartilages,  and  the  interior  of  the  larynx, 
especially  the  false  vocal  cords.  Not  rarely  the  process  extends  down 
to  the  cartilage.  In  correspondence  with  the  seat  of  the  ulcer,  peri- 
chondritis develops  most  frequently,  with  more  or  less  extensive  necro- 
sis of  the  cricoid  cartilage  and  the  arytenoid  cartilages,  which  destroys 
the  former  throughout  a  large  extent  and  may  involve  the  latter  in 
necrosis,  with  total  exfoliation.  The  process  may  even  extend  into  the 
mediastinum,  leading  to  emphysema  and  infiltration  of  the  mediastinum 
Avith  pus,  as  occurred  in  several  cases  cited  by  Keen.^ 

Not  much  less  common  are  ulcerative  lesions  of  the  epiglottis. 
Generally,  these  remain  superficial,  surrounding  the  margin  of  the 
epiglottis  individually  or  in  groups.  At  times  they  extend  down  to  the 
cartilage  and  cause  exfoliation  of  small  portions  of  its  border.  Exten- 
sive destruction  of  the  epiglottis  is  rare,  and  when  it  occurs  it  may 
involve  more  than  half  of  this  structure.  Perichondritis  and  necrosis 
of  the  thyroid  cartilage  appears  to  be  by  far  the  least  common. 

^  Surgical  Co')nplications  and  Sequels  of  Typhoid  Fever,  Philadelphia,  1898. 
^  Loc.  cit. 


114  TYPHOID  FEVER. 

With  regard  to  the  mode  of  origm  of  tyjjhoid  ulceration  of  the 
larj'nx  and  its  sequels  the  last  Avord  has  not  yet  been  said.  To  consider 
them  as  "  decubital,"  m  the  strict  sense  of  the  word,  as  older  \vriters 
did,  is  as  little  justified  as  the  assumption  that  the  more  extensive  lesions 
are  due  to  true  diphtheria.  A  portion  of  the  ulcers,  especially  those  of 
the  posterior  wall  of  the  larynx,  undoubtedly  arise  from  supci'hcial 
erosions  and  fissures  of  the  mucous  membrane,  which  then  probably 
increase  in  extent  through  secondary  infection.  In  another  group  of 
cases  the  condition  is  certainly  dependent  upon  a  peculiar  affection  of 
the  mucous  membrane  in  the  form  of  an  infiltration  of  its  lymph- 
follicles,  which  in  its  nature  is  comparable  with  that  constantly  present 
in  the  mtestine  and  other  organs.  These  swollen  lymph-follicles  occur 
especially  at  the  base  of  the  epiglottis,  on  the  posterior  wall  bet^'cen  the 
arytenoid  cartilages  and  at  the  posterior  attachment  of  the  vocal  cords, 
and  they  appear,  like  the  other  lymphoid  infiltrations,  to  undergo  dis- 
integration, and  thus  to  afford  the  first  impulse  to  the  process  of 
ulceration.  Further  careful  microscopic  and  bacteriologic  examinations 
are  still  needed  to  establish  the  specific  character  of  these  lesions. 
Luscatello  ^  has  reported  the  cultivation  of  the  typhoid-bacillus  from 
the  inflamed  mucosa  of  the  epiglottis  in  one  case,  but  his  report  is  very 
incomplete.  More  satisfactory  is  the. report  of  Schulz,^  as  to  finding 
that  organism  both  in  sections  and  in  cultures  from  the  swollen  lym- 
phoid nodules. 

The  opinion  is  held  by  some  that  perichondritis,  with  abscess-forma- 
tion, may  develop  independently,  without  antecedent  ulceration  of  the 
mucous  membrane.  Conditions  of  this  kind  would  be  comparable  with 
the  typhoid  periostitis  of  the  long  bones  and  the  ribs,  and  examination 
of  the  pus  for  typhoid-bacilli  would  be  especially  desirable. 

The  trachea  and  the  large  bronchi  are  rarely  the  seat  of  profound 
alterations.  Generally,  at  the  height  of  the  disease  their  mucous  mem- 
brane is  markedly  reddened,  covered  with  scanty,  viscid  secretion,  and 
the  seat  here  and  there  of  small  erosions.  Only  exceptionally  do  these 
become  deepened  into  actual  ulcers,  and  but  rarely  do  they  give  rise 
to  perichondritis,  necrosis  of  cartilage,  and  peribronchial  suppuration. 
A  number  of  observers,  particularly  Griessinger,  report  the  occurrence 
of  pseudomembranous  diphtheric  deposits.  These  are  in  any  event 
extremely  rare,  and  they  have  not  yet  been  subjected  to  thorough  study 
by  modern  methods.  The  occurrence  of  extensive  fibrinous  tracheo- 
bronchitis (Eisenlohr)  is  noteworthy,  and  it  is  to  be  distinguished  clearly 
by  its  clinical  course  from  true  diphtheric  lesions. 

1  Berl.  klin.  Woch.,  1894,  Bd.  xxxi.,  No.  16.  "^  Ibid.,  Bd.  xxxv.,  No.  34. 


PATHOLOGY.  115 

In  not  a  few  cases  there  is  considerable  recent  hyperplasia  of  the 
bronchial  glands.  This  is  not  a  condition  associated  with  tlie  local 
alterations  in  the  air-passages,  but  is  a  part  manifestation  of  the  general 
typholymphoid  hyperplasia.  The  smaller  and  the  smallest  bronchi, 
like  the  larger,  present  generally,  at  the  height  of  the  disease  and 
throughout  the  entire  febrile  stage,  only  slight  swelling  of  the  reddened 
mucous  membrane  and  scanty  secretion  from  it.  With  the  majority  of 
recent  observers,  I  consider  this  catarrh  as  specific  and  peculiar  to 
typhoid  fever.  The  atelectasis  and  lobular  pneumonia,  which  occur 
so  frequently,  are  intimately  associated  with  the  typhoid  bronchiolitis. 
These  processes  have  by  no  means  been  sufficiently  studied  bacterio- 
logically.  In  a  large  proportion  of  cases  the  condition  belongs,  so  far 
as  streptococci  and  staphylococci  act  as  the  cause  of  the  inflammatory 
process,  among  the  true  complications ;  while,  accordmg  to  the  examina- 
tions of  Polynfere,^  Finkler,^  and  others,  in  another  proportion  it  is  due 
directly  to  the  activity  of  the  typhoid-bacillus. 

I/UngfS. — After  death  following  severe,  long-continued  attacks  of 
typhoid  fever,  not  rarely  also  after  death  at  the  lieight  of  the  febrile 
stage,  hypostatic  condensation  is  found  in  the  posterior  and  inferior 
portions  of  the  lungs.  This  condition  is  due  to  the  bronchitis,  with 
swelling  of  the  mucous  membrane  and  atelectasis,  involving  first  and 
preferably  the  portions  of  the  lungs  above  mentioned,  and  also  to  the 
cardiac  weakness  and  the  influence  which  the  position  of  the  body  has 
upon  the  distribution  of  the  blood,  the  latter  factor  exhibiting  twofold 
intensity  under  the  conditions  present.  The  generally  short  duration  of 
typhoid  fever  in  children,  and  the  much  less  common  occurrence  of 
cardiac  weakness,  are  undoubtedly  responsible  for  the  fact  that  hypostatic 
splenization  is  much  less  common  in  them  than  in  adults. 

Among  the  lobar  inflammatory  processes  in  the  lungs  in  the  course 
of  typhoid  fever  true  fibrinous  pneumonia  plays  an  important  role. 
Horton-Smith  ^  says  :  "  It  occurred  in  nearly  5  per  cent,  of  our  fatal 
cases,"  It  was  present  in  over  8  per  cent,  of  2000  autopsies  at  the 
Munich  Pathologic  Institute.*  Clinically,  it  occurred  6  times  in  500 
cases  reported  by  Frankel,^  and  it  has  been  present  15  times  in  829 
cases  at  the  Johns  Hopkins  Hospital.  The  disorder  is  almost  always 
dependent  upon  the  Frankel-Weichselbaum  diplococcus,  while  the 
bacillus  of  Friedlander  acts  as  the  cause  only  in  isolated  instances. 
Undoubtedly,  mixed  infections  occur,  especially  of  Diplococcus  pneu- 

1  These,  Paris,  1889.  ^  Die  aeuten  Lttngenentzimdungen,  Wiesbaden,  1891. 

*  Loc.  cit.  *  Munch,  med.   Woch.,  1891,  Nos.  3  and  4. 

5  Deutsch.  med.  Woch.,  1899,  Bd.  xxv.,  No.  16. 


116  TYPHOID  FEVER. 

mouite  with  streptococci  and  ytai)hylococci.  They  have,  however,  not 
yet  been  so  thoroughly  studied  anatomically  that  any  definite  statement 
can  be  made  with  regard  to  their  frequency.  Not  rarely  macroscopic 
inspection  of  the  cut  surface  of  the  lung  will  raise  a  sus]>icion  that  an 
instance  of  this  compliciited  variety  may  be  present. 

In  rare  instances  streptococcic  pneumonia,^  which,  as  has  been 
mentioned,  generally  occurs  in  lobular  form,  is  found  in  lobar  form. 
Still  less  frequently  staphylococcic  pneimionia  appears  to  occur  as  a 
mono-infection  m  cases  of  typhoid  fever. 

Mixed  infections  of  streptococci  and  staphylococci  with  Bacillus 
typhosus  have  also  been  described.  The  question  as  to  whether  cases 
of  true  pneumotyphoid  occur  has  lately  been  considered  by  A.  Friinkel,^ 
who  says  :  "  One  can  say  definitely  that  the  occurrence  of  a  pneumo- 
typhoid in  the  old  sense — that  is,  a  pneumonia  occurring  as  the  expres- 
sion and  result  of  the  primary  localization  of  the  typhoid-bacillus  in  the 
lungs — must  be  regarded  as  not  yet  demonstrated."  Whether  a  sec- 
ondary lobar  pneumonia  occurring  during  the  course  of  typhoid  fever 
may  be  caused  by  the  typhoid-bacillus  alone  is  also  open  to  some 
question,  notwithstanding  the  fact  that  several  cases  reported  as 
such  are  contained  in  the  literature.  In  some  of  these  cases  cultures 
were  made  so  late  in  the  disease  that,  even  though  the  pneumococcus 
had  been  present  earlier,  it  might  have  died  out.  Such  are  the  cases 
reported  by  Bensaude^  (Observation  IX.)  and  by  Foa  and  Bordoni- 
Uifreduzzi.* 

The  second  case  reported  by  Bensaude^  (Observation  LXIX.)  is 
more  convincing,  but  the  bacteriologic  report  is  incomplete.  Other 
reports  of  cases  of  lobar  pneumonia  due  to  the  typhoid-bacillus  have 
been  made  by  Chantemesse,  Finkler,  Bruneau,^  and  others. 

Gangrenous  portions  of  hmg,^  or  those  in  a  state  of  hypostatic  splen- 
ization,  or  even  lobar  pneumonia^  due  to  the  pneumococcus,  may 
undoubtedly  be  invaded  by  typhoid-bacilli.  Although,  in  view  of  the 
great  variety  of  inflammatory  conditions  which  may  be  induced  by  the 
t}^hoid-bacillus,  it  is  possible  that  it  may  cause  a  true  lobar  pneumonia, 
yet  this  form  of  lung  involvement,  if  it  ever  occurs,  must  do  so  very 

^  See  the  case  of  Koch  from  my  clinic,  Inaug.  Diss.,  Leipsic,  1896;  also  Neu- 
mann, Berl'm.  klin.  TFocA.,  1886,  No.  6;  Tinkler,  Congress-verhandlungen  f.  innere 
Medicin,  1888  u.  1889. 

■■<  Deutsch.  med.  Woch.,  1899,  Bd.  xxv.,  No.  16. 

3  These,  Paris,  1897.  *  Riformamed.,  1887,  No.  1. 

°  Loc.  cit.  ^  These,  Paris,  1893. 

'  Flexner  and  Harris,  Juhns  Hopkins  Hosp.  Bull.,  1897. 

8  A.  Friinkel,  Zeit.f.  klin.  Med.,  Bd.  x.,  S.  439. 


PATIfOLOGY.  117 

rarely.  Accurate  histologic  and  bactcriologic  reports  are  much  needed 
to  clear  up  this  most  interesting  and  important  point.  All  of  the  varieties 
of  pneumonia  mentioned  as  occurring  in  the  course  of  typhoid  fever 
appear,  though  rarely,  to  be  capable  of  giving  rise  to  the  development 
of  abscess  of  the  lungs.  Metastatic  abscesses,  as  local  manifestations 
of  a  complicating  pyemia,  have  also  been  observed.  Pulmonary  gangrene 
appears  to  occur  somewhat  more  frequently,  sometimes  as  the  sequel 
of  lobar,  especially  fibrinous,  pneumonia,  in  severe  protracted  cases, 
and  in  previously  debilitated  individuals,  and  also  as  the  result  of 
putrid-purulent  embolism,  and,  finally — and  this  is  of  especial  impor- 
tance— as  the  result  of  aspiration-pneumonia  of  most  varied  origin. 
The  last-named  condition  may  be  due  to  putrid,  infectious  materials, 
derived  from  the  food  if  the  mouth  is  not  well  cared  for,  or  may  arise 
from  purulent,  putrid  affections  of  the  mouth  and  of  the  commencement 
of  the  respiratory  passages,  dental  caries  with  gingival  abscess,  purulent, 
gangrenous  tonsillitis,  or  from  laryngeal  ulcers  with  perichondritic 
abscess  and  necrosis  of  cartilage.  Spontaneous  gangrene  of  the  lungs, 
as  was  observed  by  Liebermeister,  has  not  occurred  in  my  experience. 

Hemorrhagic  infarction  of  the  lung,  as  well  as  the  same  condition  in 
the  spleen  and  the  kidneys,  is  not  rarely  found  in  the  bodies  of 
those  dead  of  typhoid  fever.  The  infarct  may  undergo  involution 
by  absorption  and  contraction,  eventually  with  cicatrization ;  or  it 
may  undergo  purulent  or  even  gangrenous  disintegration,  generally 
then  with  the  development  of  exudative  pleurisy,  especially  empyema. 
The  peripheral  situation  and  the  wedge-shape  of  the  majority  of  these 
infarcts  are  at  once  indicative  of  their  embolic  origm.  As  a  matter  of 
fact,  mural,  softened  thrombi  are  under  such  conditions  frequently 
found  in  the  right  side  of  the  heart,  particularly  in  the  auricle  and  in 
the  auricular  appendix.  Such  emboli  may  be  derived  also  from  the 
large  branches  of  the  pulmonary  artery  itself,  which  not  rarely  exhibits 
acute  alterations  of  the  intima  in  cases  of  typhoid  fever.  In  connection 
with  infarction,  sudden  death  is  to  be  borne  m  mind,  the  cause  of 
which  is  to  be  looked  for  in  embolism  of  a  main  branch  of  the 
pulmonary  artery.  The  source  of  this  embolus  also  may  be  found  in 
the  heart  or  in  the  large  peripheral  vein  of  the  body. 

Pleurisy  in  the  form  of  a  more  or  less  extensive  fibrinous  deposit  is 
not  rare  as  a  condition  associated  with  the  various  forms  of  pneumonia 
complicating  typhoid  fever,  and  under  such  circumstances,  in  so  far  as 
previous  investigation  has  disclosed,  is  to  be  attributed  to  the  micro- 
organisms responsible  for  the  pulmonary  disorder.  Fibrinous  and  septic 
pneumonia   also  lead  at   times  to  empyema.     Serous  or  serofibrinous 


118  TYPHOID  FEVER. 

pleuritic  efFu.sions  of  considerable  amount  are  remarkably  rare  in  the 
course  of  typhoid  fever.  Pneumothorax  occurs  only  exceptionally,  and 
generally  as  the  sequel  of  pui'ulent  or  gangrenous  focal  disease  of  the 
lungs. 

The  role  of  Bacillus  typhosus  in  the  serous  pleurisies  and  empyemas 
complicating  typhoid  fever  has  recently  been  discussed  by  Friinkel,^ 
Remliuger/  and  others.  Friinkel  observed  4  cases  of  empyema  among 
500  cjises  of  typhoid  fever.  Cultures  from  the  purulent  efflisions 
showed  in  2  cases  B.  typhosus ;  in  the  third,  streptococcus ;  and  in  the 
fourth,  pneumococcus.  Among  829  cases  of  typhoid  fever  m  the  Johns 
Hopkins  Hospital,  but  1  case  of  empyema  occurred.  The  pus  in  this 
case  contained  the  typhoid-bacillus  in  very  large  numbers.  Remlinger 
has  reported  8  cases  of  empyema  and  of  pleurisy  with  effusion  from  the 
exudate,  in  7  of  which  the  typhoid-bacillus  was  isolated.  He  has  also 
collected  19  similar  cases.  Still  several  other  cases  are  contained  in  the 
literature.  While  the  bacteriologic  examination  in  some  of  the  earlier 
cases  may  be  open  to  doubt,  there  can  be  no  question  that  in  a  number 
of  cases  the  typhoid-bacillus  has  occurred  alone,  and  its  primary  etiologic 
significance  seems  fairly  well  established. 

Tuberculosis  is  an  important  complication  of  typhoid  fever,  especially 
tuberculous  disease  of  the  lungs.  It  occurs  in  various  forms,  namely, 
as  part  manifestation  of  a  complicating  general  miliary  tuberculosis ;  as 
acute  cheesy,  lobular,  rarely  lobar,  pneumonia ;  in  the  form  of  acute 
tuberculous  peribronchitis ;  or  as  a  direct  exacerbation  and  acute  dis- 
semination of  a  pre-existing  apical  tuberculosis,  hitherto  pursuing  a 
sluggish  course.  Also  in  the  other  forms,  tuberculous  affections  of  some 
standing  of  the  lungs  and  the  bronchial  glands  or  of  more  remote  organs 
may  always  be  found  after  death  as  the  source  of  the  recent  tuberculosis. 
Also  the  occurrence  of  tuberculosis  as  a  mixed  infection  is  interesting, 
and  has  been  carefully  studied  in  a  few  cases.  Especially  in  cases  of 
t^^ihoid  pneumonia  the  tubercle-bacillus  has  been  foimd  repeatedly 
together  with  the  pneumococcus  of  Frankel  and  Weichselbaum,  then 
naturally  in  conjunction  with  correspondingly  complicated  histologic 
conditions. 

ALTERATIONS  IN  THE  NERVOUS  SYSTEM. 

In  contrast  to  the  marked  predominance  of  clinical  manifesta- 
tions with  reference  to  the  central  nen^ous  system  in  cases  of  typhoid 
fever  pursuing  a  severe  course,  the  anatomic  findings  are  extremely 
slight.     Doubtlessly,  this  is  due  to  the  fact  that  the  profound  nei'\'ous 

1  Loc.  cit.  2  22ei,.  de  Med.,  1900,  No.  12. 


PATHOLOGY.  119 

disturbances  are  attributable  especially  to  a  specific  intoxication  depend- 
ent upon  the  typhoid-bacilli,  and  which  generally  gives  rise  to  a  transi- 
tory impression  wholly  disproportionate  histologically  to  the  intensity  of 
its  symptoms. 

Cerebral  Meninges. — The  dura  not  rarely  presents  hyperemia 
and  more  or  less  marked  recent  adhesion  to  the  inner  surface  of  the 
skull,  which  in  turn  is  then  generally  the  seat  of  osteophytic  deposits. 
The  large  veins  and  the  sinuses  are  often  distended  with  dark  fluid 
blood,  while  the  formation  of  thrombi  appears  to  occur  only  exception- 
ally, and  then  at  a  late  stage  in  cases  of  protracted  course. 

The  pia=arachnoid  is  usually  the  seat  of  edematous  infiltration,  slight 
cloudiness,  injection,  and  adhesions,  and  there  is  usually  an  increase  in 
the  clear  or  slightly  turbid  ventricular  fluid.  Quite  noteworthy  are 
the  observations  of  Fr.  Schulze,^  who  noted,  on  microscopic  examina- 
tion of  the  brain  and  meninges  of  cases  that  during  life  had  exhibited 
more  or  less  pronounced  symptoms  of  meningitis,  in  addition  to  the 
macroscopic  appearances  mentioned,  a  small-cell  infiltration  of  the 
meninges  and  a  continuance  of  this  process  along  the  vessels  into  the 
cerebral  tissue. 

Subarachnoid  menuageal  hemorrhages  were  early  described  by  Cho- 
mel  as  a  rare  condition,  and  later  by  Hoffmann  and  Griessinger.  It 
appears  that  they  may  occur  at  an  early  stage,  as  demonstrated  by  the 
2  cases  of  Griessinger,  who  observed  them  as  early  as  the  second  week 
of  the  disease. 

Purulent  cerebral  and  cerebrospinal  meningitis  are  mentioned  excep- 
tionally in  the  earlier  literature,  but  have  only  recently  been  specially 
pointed  out  on  account  of  their  clinical  significance  (Duchek,  Griessinger, 
Buhl,  Leyden,  Erb,  Curschmann).  These  affections  may,  as  I  have 
emphasized,^  occur  as  early  as  the  first  week  of  the  disease.  They  rarely 
terminate  fatally.  The  varieties  that  occur  later,  toward  the  end  of 
the  febrile  period  or  even  shortly  after  defervescence,  are  far  more 
severe,  and  they  more  frequently  come  to  autopsy.  Under  these  condi- 
tions extensive  and  profound  evidences  of  inflammation  often  appear  in 
the  form  of  fibrinopurulent  infiltration  of  the  cerebral  and  spinal  pia- 
arachnoid.  Whether  these  processes  are  identical  etiologically  or  are  of 
varied  origin  is  involved  in  doubt,  as  thorough  histologic  and  bacterio- 
logic  studies  are  yet  wanting.  It  is  not  improbable  that  in  a  portion 
of  the  cases  the  bacillus  of  Eberth  is  the  sole  or,  at  least,  the  predomi- 

^  Verhandl.  d.  Cong.  f.  inn.  Med.,  Wiesbaden,  Bd.  v.,  S.  469  and  following. 
_^  Ibid.,  Bd.  v.,  S.  469  and  following.     See  also  Wolff,  Arch.  f.  klin.  M^d.,  Bd. 
xliii.     (Reports  from  my  service  at  Hamburg. ) 


120  TYPHOID  FEVER. 

uant  exciting  agent  of  suppuration.  In  late  years  at  least  10  genuine 
cases  have  been  reported  in  which  the  typhoid-baciUus  was  isolated  in 
pure  culture.  These  have  been  collected  up  to  July,  1900,  by  Hof- 
mann.^  An  additional  case  has  lately  occurred  in  the  Johns  Ho})kins 
Hospital.  In  other  ciises,  particularly  in  those  with  associated  fibrinous 
pneumonia,  there  is  good  ground  to  consider  the  Frjinkel-Weichselbauni 
diplococcus  as  the  causative  factor.  Still  other  cases  are  to  be  attrib- 
uted, in  all  probability,  to  the  exciting  agent  of  true  (epidemic)  cerebro- 
spinal meningitis.  Apart  from  isolated  bacteriologic  observations,  the 
fact  that  meningitic  symptoms  are  encountered  with  remarkable  frequency 
in  cases  of  typhoid  fever  occurring  in  places  and  at  times  where  both 
tliseases — cerebrospinal  meningitis  and  typhoid  fever — prevail  together  is 
also  in  favor  of  this  view.-  It  is  undoubted  finally  that  also  strepto- 
cocci or  staphylococci  alone,  or  in  the  form  of  a  mixed  infection  with 
other  micro-organisms,  may  give  rise  to  purulent  meningitis.  This  is 
the  case  especially  as  a  part  manifestation  of  complicating  septicemia, 
but  it  must  be  emphasized  that  only  a  small  minority  of  all  cases  of 
typhoid  fever  complicated  by  pyemia  exhibit  this  localization. 

Another  important  variety  of  secondary  purulent  meningitis  is  that 
following  purulent  inflammation  of  the  middle  ear,  with  meningo- 
phlebitis,  sinus-thrombosis,  and  caries  of  the  petrous  bone.  It  is  the 
more  noteworthy  from  the  fact  that  the  aifectiou  of  the  ear  is  not  rarely 
overlooked  during  life  in  the  profoundly  stupid  or  completely  comatose 
patient. 

With  regard  to  the  condition  of  the  cerebral  tissue,  it  may  be  said 
that  in  cases  of  typhoid  fever  it  presents  no  constantly  recurring  lesions 
or  changes  intimately  associated  with  it.  BuhP  endeavored  to  estab- 
lish cerebral  edema  with  consecutive  softening  of  varying  degree  as  an 
alteration  generally  present.  There  is  no  doubt  that  this,  associated 
even  with  moderate  dilatation  of  the  lateral  ventricles,  is  demon- 
strable in  many  cases.  Focal  softening  is  quite  rare,  and,  when  it 
occurs,  is  the  result  of  thrombosis  of  the  cerebral  arteries  that  have 
undergone  the  degeneration  previously  mentioned  (obliterating  endarter- 
itis) or  of  coagulation  in  one  or  more  cerebral  sinuses  or  large  veins. 

Meynert  has  called  attention  to  a  yellowish-brown  discoloration  of 
the  cerebral  cortex,  the  surface  of  the  corpora  striata,  the  optic  thalami, 
and  the  coqjora  quadrigemina,  which  he  was  able  to  trace  microscopi- 

1  Deutsch.  med.  WocJi.,  July  12,  1900. 

''■  I  was  struck  by  this  particularly  during  the  epidemic  at  Hamburg  in  1886-87. 
See  also  Wolff  [loc.  cit.). 

^  Buhl,  "  Ueber  den  Wassergehalt  des  Gehirns  bei  Typhus,"  Zeit.  f.  ration.  Med., 
1858. 


PATHOLOGY.  '  121 

cally  to  a  diffuse  yellowish  discoloration  and  accunuilation  of  brownish 
pigment-granules  in  the  nervous  elements,  especially  in  the  ganglion-cells. 
The  outlines  of  the  cells  become  obliterated,  as  Hoffmann  also  observed, 
so  that  finally  the  cell-body  is  shown  indistinctly  and  principally  from 
its  pigment-content. 

Peculiar  round-cell  accumulations,  especially  in  the  perivascular 
lymph-spaces,  have  been  observed  by  von  Recklinghausen  and  Popoff. 
These  are  believed  to  be  capable  of  penetrating  the  nerve-cells  and 
causing  them  to  undergo  degeneration.  These  observations,  which  are 
at  present  difficult  of  interpretation,  have  been  confirmed  from  various 
sources  (Duke  Carl,  of  Bavaria,  Blaschko,  and  others).  Hemorrhage 
into  the  substance  of  the  brain  appears  to  be  extremely  rare.  I  have 
observed  only  2  cases  of  the  kind.  Abscess  of  the  brain  occurs  occa- 
sionally as  a  sequel  of  purulent  inflammation  of  the  middle  ear,  or  as  a 
result  of  metastasis.  In  one  instance  I  have  observed  such  a  condition 
in  connection  with  general  pyemia  in  the  sequence  of  a  putrid  bed-sore, 
and  in  another  instance  in  connection  with  abscess  of  the  lung. 

Anatomic  alterations  in  the  medulla  oblongata  and  the  Spinal 
cord  are  almost  unknown.  Kiimmell  has  observed  2  cases  of  bulbar 
hemorrhage.  One  case  has  occurred  in  my  experience,  having  symp- 
toms of  acute  bulbar  paralysis  and  terminating  fatally,  in  which  the 
autopsy  disclosed  softening  and  capillary  hemorrhages  into  the  tissue 
of  the  medulla  oblongata.  Microscopic  examination  was,  unfortunately, 
not  made. 

With  regard  to  the  spinal  cord,  the  statement  is  encountered  that 
it  often  exhibits  hyperemia  and  also  a  hyperemic  state  of  its  meninges. 
In  isolated  instances  foci  of  myelitis  and  especially  the  occurrence 
of  circumscribed  anterior  poliomyelitis  (Shore)  have  been  mentioned. 
In  one  case,^  in  which  the  course  of  an  attack  of  typhoid  fever  was 
dominated  exclusively  by  spinal  symptoms,  and  presented  the  clinical 
picture  of  an  acute  ascending  (Landry's)  paralysis,  numerous  typhoid- 
bacilli  could  be  demonstrated  microscopically  in  transverse  sections  of 
the  spinal  cord,  and  could  be  cultivated  also  from  its  tissue.  In 
structure,  the  cord  presented  insignificant  alterations  only.  The  case 
sheds  light  upon  quite  a  similar  one  of  Leudet's,^  presenting  symptoms 
of  acute  Landry's  paralysis  during  convalescence  from  a  mild  attack 
of  typhoid  fever,  which  terminated  fatally,  and  which  upon  post- 
mortem examination  exhibited  no  material  changes  in  the  spinal  cord. 
In  another  case,^  also  showing  the  clinical  course  of  an  acute  ascending 

1  Curschmann,   Verhandl.  d.  Gong.  f.  inn.  Med.,  1886. 

2  Gfaz.  med.  de  Paris,  1861,  No.  19.  "  Curschmann,  loc  cif. 


1:^2  TYPHOID  FEVER. 

pui-alysis,  capillary  hemorrhages  and  areas  of  softeumg  were  found  in 
the  medulla.  The  bacteriologic  examiuation  in  this  case  gave  negative 
results.      Kiimmell '  has  reported  a  similar  case. 

Fiually,  Schiif "  has  reported  a  case  with  a  very  similar  clinical  course, 
but  wliich  was  very  acute,  death  occurring  in  eighteen  hours.  The  ex- 
amination of  the  cord  in  this  aise  showed  an  acute  hemorrhao;ic  transverse 
myelitis  at  the  level  of  the  fourth  and  fifth  cervical  segments.  Cultures 
in  this  case  were  also  negative.  All  of  these  anatomic  conditions  must 
be  considered  as  extremely  rare  as  compared  with  the  presence,  not 
uncommonly,  of  marked  spinal  symptoms.  In  this  connection  there 
exists  a  great  deficiency  in  the  study  of  typhoid  fever  at  the  autopsy- 
table. 

The  peripheral  nervous  system  likewise  has  been  but  rarely 
studied  in  cases  of  typhoid  fever.  In  association  with  certain  clinical 
manifestations  the  anatomic  lesions  of  parenchymatous  neuritis  have 
here  and  there  been  found,  at  times  throughout  a  wide  distribution 
(Pitres  and  Vaillard). 

Alterations  in  the  Organs  of  Special  Sense. — Little  has 
hitherto  been  learned  anatomically  with  regard  to  the  eyes,  which  clini- 
cally exhibit  various  disturbances.  Ulceration  of  the  cornea,  iritis,  and 
iridochoroiditis,  and,  in  isolated  instances,  optic  neuritis  have  been 
observed.  The  changes  in  the  ears  have  been  more  frequently  and  more 
thoroughly  studied.  Although  by  no  means  all,  at  least  most  of  the 
disturbances  of  this  organ  are  attributable  to  extension  of  catarrhal 
and  more  profound  disturbances  from  the  nasopharyngeal  cavity,  the  ton- 
sils, and  adjacent  structures.  Thus,  catarrhal  conditions  of  the  mucous 
membrane  of  the  Eustachian  tube  and  the  tympanic  cavity  are  among 
the  more  common  complications.  At  times  purulent  catarrh  of  the  mid- 
dle ear  occurs,  with  perforation  of  the  tympanic  membrane,  and,  further, 
purulent  aifections  of  adjacent  structures,  especially  of  the  cells  of  the 
mastoid  process,  the  related  veins,  and  the  adjacent  sinuses.  Diphtheric 
affections  of  the  Eustachian  tube  and  of  the  middle  ear  have  also  been 
observed  repeatedly  as  the  immediate  extension  of  similar  processes  in 
the  nasopharyngeal  structures. 

ANALYSIS  OF    THE  INDIVIDUAL    SYMPTOMS;    COMPLI- 
CATIONS. 

The  clinical  picture  of  typhoid  fever,  so  extraordinarily  variable  with 
regard  to  severity,  duration,  grouping,  and  development  of  the  individual 
symptoms,  as  well  as  to  sequels  and  terminations,  can,  on  the  whole,  be 

'  Zelt.f.  klin.  Med.,  1881,  Bd.  ii.         ^  j)p,^i^  Arch.  f.  klin.  Med.,  Bd.  Ixvii.,  1900. 


SYMPTOMS  AND   (JOM PLICATIONS.  123 

attributed  to  two  principal  factors,  namely,  the  vital  activity  of  the 
typhoid  virus  and  its  effects  upon  the  body,  and  the  individual  reaction 
of  the  patient.  While  our  views  witli  regard  to  the  second  factor — ^a 
result  of  constant  change  and  gradual  evolution  of  clinical  knowledge — 
are  at  the  present  day  extended  and  deepened  in  all  directions,  the  first, 
the  relations  of  the  typhoid-bacillus  to  the  complete  picture  of  the  dis- 
ease and  its  individual  symptoms,  is  still  in  its  incipiency  in  spite  of  a 
large  number  of  isolated  facts.  At  present  it  may  be  definitely  stated 
that  the  effects  of  the  typhoid-bacillus,  viewed  collectively,  consist  in 
its  local  and  its  general  manifestations.  The  latter  is  attributable  essen- 
tially to  the  toxins  generated  by  the  bacillus,  the  earliest  knowledge  of 
which  we  owe  to  Briefer  and  Frankel.  In  addition  to  the  effects  of  the 
bacillus  of  Eberth,  those  of  other  pathogenic  micro-organisms  are  daily 
becoming  more  important,  being  exhibited  alone  or  in  combination  with 
the  former  in  certain  organs  or  groups  of  organs.  Considered  strictly, 
only  the  first  group  of  symptoms  should  at  the  present  day  be  included 
in  the  actual  typhoid  disease,  while  the  conditions  dependent  partially  or 
exclusively  upon  other  infectious  agents  are  to  be  considered  as  compli- 
cations. 

Also,  in  the  prebacteriologic  period,  complications  and  sequels  were 
considered  apart  from  the  actual  symptoms  of  the  disease,  although  from 
other  points  of  view.  At  the  present  day  tke  previous  division  appears 
quite  arbitrary,  but  we  are  unable  to  replace  it  with  anything  better.  If 
an  attempt  were  made  to  insist  upon  such  a  division  from  the  modem 
standpoint,  the  objection  would  at  once  arise  that  the  present  state  of 
bacteriologic  investigation  of  typhoid  fever  is  by  no  means  such  as  to 
justify  a  separation  of  the  actual  symptoms  of  the  disease  from  the 
complications.  In  detail  much  that  is  new  and  surprising  may  be 
brought  forward.  A  whole  series  of  alterations  that  until  recently  were 
considered  as  complicating  and  independent  of  the  typhoid  germ  are 
now  recognized  as  mixed  infections  of  typhoid-bacilli  and  other  patho- 
genic micro-organisms,  or  even  dependent  upon  the  typhoid-bacillus 
alone.  It  may  suffice  in  this  connection  to  refer  only  to  the  purulent 
processes,  to  affections  of  the  bones  and  joints,  to  certain  forms  of  pneu- 
monia and  pleuritic  effusions,  as  well  as  to  some  manifestations  on  the 
part  of  the  nervous  system  and  the  heart.  Under  existing  conditions, 
however,  it  will  be  better  in  the  following  description  to  abstain  from  a 
rigid  separation  of  the  complications  from  the  actual  symptoms  of  the 
disease,  and  to  treat  of  both  together.  In  so  far  as  this  may  be  possible, 
an  effort  will  be  made  to  present  the  various  processes  as  specific,  as 
pure  complications,  or  as  mixed  infections,  as  this  differentiation  is  of 


124  TYPHOID  FEVER. 

decisive  importance  for  the  comjirebension  of  the  disease  generally  and 
for  its  further  study. 

ALTERATIONS  EST  THE  EXTERJMAL  INTEGUMENT. 

Some  statements  with  regard  to  the  condition  of  the  external  integu- 
ment in  cases  of  typhoid  fever  have  been  made  m  the  description 
of  the  general  clinical  picture  and  the  anatomic  alterations.  The  skm 
in  all  stages  of  typhoid  fever  exhibits  various  manifestations,  inn)ortant 
from  a  diagnostic  standpoint  as  well  as  in  their  bearing  upon  the 
course  and  the  termination  of  the  disease.  One  of  the  most  frequent 
and  most  important  is  the  roseola.  This  has  been  specifically  desig- 
nated as  the  typhoid  roseola,  and  with  what  propriety  will  be  shown  in 
the  following  statements. 

The  roseola  (tache  rosee  lenticulaire,  Louis)  appears  in  the  form  of 
small,  roundish,  well-circumscribed  red  spots,  varying  in  size  from  that 
of  the  head  of  a  pin  to  that  of  a  lentil,  and  always  slightly  elevated, 
which  fade  completely  on  pressure  (best  made  with  a  glass  pleximeter) 
at  every  stage,  and  thus  are  shown  to  be  purely  hyperemic.  Pale  red 
and  punctate  when  they  first  appear,  the  roseolse  rapidly  become  larger 
and  darker  in  color.  They  are  almost  always  discrete  ;  here  and  there 
two,  rarely  several,  coalesce.  They  appear  first  in  the  second  half  of 
the  first  week  or  in  the  beginning  of  the  second  week  of  the  disease. 
Cases  in  which  the  exanthem  appears  later,  not  before  the  middle  or  at 
the  end  of  the  second  week,  are  rare.  Exceptionally,  roseolse  appear 
early,  from  the  second  to  the  fourth  day  of  the  disease.  I  have 
observed  this  especially  in  women  and   children. 

The  roseolse  appear  first  upon  the  chest,  the  abdomen,  and  the  back. 
Upon  the  back  they  often  appear  twelve,  even  twenty-four,  hours 
earlier  than  upon  the  abdomen  and  the  chest,  and  in  the  situation  first 
named  they  are  not  rarely  somewhat  larger  than  in  the  others.  From 
the  trunk  the  roseolous  eruption  generally  does  not  extend  further, 
although  in  exceptional  instances  it  may  invade  the  arms  and  the 
thighs,  and  quite  exceptionally  the  forearms,  the  dorsa  of  the  hands,  the 
legs,  and  the  feet.  Such  extensive  distribution  upon  the  extremities 
almost  always  presupposes  a  relatively  dense  involvement  of  the  trunk. 
It  may  be  accepted  as  a  rule  that  this  part  of  the  body  is  preferably 
and  most  densely  the  seat  of  the  roseolse,  and  their  nmnber  diminishes 
progressively  the  further  from  the  trunk  the  affected  part  of  the  body 
is  situated.  In  a  case  in  which  a  roseolous  exanthem  was  more  dense 
upon  the  distal  portions  of  the  extremities  than  upon  the  proximal  por- 
tions, and  even  upon  the  trunk,  I  would  from  this  alone  have  some 


SYMPTOMS  AND  COMPLTCATIONS.  125 

liesitancy  in  making  a  diagnosis  of  typhoid  fever.  Roseolie  very  rarely 
appear  upon  the  face.  Only  exceptionally  have  I  found  them  upon 
the  neck,  and  even  at  the  lower  border  of  the  inferior  maxillary 
bone. 

In  general  and  in  comparison  with  the  efflorescences  of  other  infec- 
tious diseases  the  roseolous  exanthem  of  typhoid  fever  is  not  almndant. 
When  it  develops  smiultaneously  in  large  number  and  in  great  density 
the  appearance  created  is  striking,  and  great  care  in  diagnosis  will  be 
required,  as  confusion  with  other  infectious  diseases  is  readily  possible. 
Thus,  I  have  now  and  then  observed  syphilitic  roseola  with  eruptive 
fever  and  enlargement  of  the  spleen  to  give  rise  to  unpleasant  confusion. 

In  the  large  majority  of  cases  the  roseolse  are  present  at  one  time 
singly  or  in  small  number,  from  5  to  10  or  30.  In  young  children  they 
are,  in  my  experience,  generally  still  fewer  than  in  adults.  In  the 
latter  the  number  is  again  diminished  in  advanced  age.  With  regard  to 
sex,  the  exanthem  appears  in  general  to  develop  somewhat  more  abun- 
dantly in  women  than  in  men.  As  opposed  to  some  observers,  as,  for 
instance,  Murchison,  I  would  distinctly  emphasize  the  fact  that  the 
roseola  may  be  entirely  wanting  throughout  the  entire  course  of  the 
disease. 

Thus,  of  1261  cases  observed  at  the  Leipsic  clinic,  persistent  absence 
of  the  roseolse  was  observed  in  260.  Undoubtedly,  the  profusion  and  the 
development  of  the  exanthem  vary  at  different  times  and  in  different 
epidemics.  In  the  year  1887  I  observed  in  Hamburg  a  relatively  much 
larger  number  of  cases  in  which  the  exanthem  was  scanty  than  in  other 
years.  Of  1601  cases,  which  at  that  time  were  carefully  examined  from  this 
point  of  view,  no  roseolse  or  but  isolated  ones  were  found  in  325.  As  opposed 
to  this  there  were  periods  in  which  the  roseolse  were  but  rarely  absent,  and  in 
which  their  average  profusion  was  especially  striking.  Perhaps  the  opinion 
of  some  observers,  that  the  roseola  is  to  be  considered  as  an  indispensable 
feature  of  typhoid  fever,  may  have  been  formed  during  such  periods. 

There  is  no  definite  relation  between  the  severity  of  the  disease  and 
the  density  of  the  roseolous  eruption,  although  I  think  I  have  observed 
complete  absence  more  frequently  in  milder  or  abortive  cases  than  m 
severe  and  long  protracted  cases.  The  eruption  is  therefore  of  diagnostic 
and  not  of  prognostic  significance.  The  duration  of  the  individual 
rose-spot  is  evidently  not  long,  on  the  average  from  three  to  five  days. 
I  believe  the  longest  period  may  be  placed  at  from  seven  to  ten  days. 
A  duration  of  fourteen  days,  as  stated  by  Trousseau,  has  not  occurred  in 
my  experience.  It  is,  however,  a  characteristic  feature  of  the  roseola 
of  typhoid  fever  that,  while  the  old  spots  disappear,  new  ones  are  con- 
stantly developing,  so  that  consequently  the  total  duration  of  the  erup- 
tion is  comparatively  long.     I  should  place  the  average  total  duration 


126  TYPHOID  FEVER. 

of  the  exanthem  as  between  twelve  and  fourteen  days.  I  have  rarely 
eneoiintered  a  longer  duration  than  three  weeks.  In  general  it  may  be 
stated  that  the  roseola?  rarely  persist  beyond  the  febrile  stage  of  the  dis- 
ease. Although  it  cannot  be  denied  that  now  and  again  isolated  roseolse 
appear  during  the'  afebrile  stage,  one  should  be  extremely  critical  in 
regard  to  them. 

During  recrudescences  and  relapses  the  roseohe  generally  reappear, 
often  in  equal  profusion  and  even  in  greater  density  than  in  the  primary 
attack,  and  they  continue  so  long  as  the  fever  persists.  Under  such 
circumstances  roseola?  may  be  found  in  the  fourth  and  the  fifth  week  of 
the  disease,  and  even  later. 

Do  roseolse  occur  also  in  the  course  of  other  diseases?  I  believe 
efflorescences  like  the  typhoid  roseolse  do  but  rarely.  The  more  skilled 
and  the  more  experienced  the  observer,  the  less  commonly  will  he  report 
instances  of  this  character.  Only  in  a  few  instances  of  acute  miliary 
tuberculosis  and  of  cerebrospinal  meningitis,  which  were  shown  on  post- 
mortem examination  not  to  be  complicated  by  typhoid  fever,  have  I 
observed  upon  the  skin  eruptions  indistinguishable  from  the  typhoid 
roseolse.  While  in  cases  of  the  acute  exanthemata,  as,  for  instance, 
small-pox  and  typhus  fever,  the  appearance  of  the  specific  eruption  is 
generally  preceded  for  a  longer  or  short  time  by  certain  evanescent 
exanthems,  I  have  but  rarely  observed  these  as  forerunners  of  the 
typhoid  roseola.  Only  in  a  few  instances  in  women  and  children,  or  in 
delicately  built,  blonde,  blue-eyed  young  persons  have  I  observed  evanes- 
cent, diffuse  or  punctate  erythemas  upon  the  trunk  and  the  extremities. 

It  is  noteworthy  that  the  roseolse,  after  they  have  faded,  generally 
leave  no  trace  ;  nor  can  they  be  demonstrated  upon  the  dead  body.  As 
the  sole  trace  remaining  during  life,  there  are  occasionally  observed  light- 
brownish  or  yellowish  spots  of  but  short  duration,  or,  more  frequently, 
slight  branny  desquamation  at  the  site  of  the  roseolse  and  in  their  immedi- 
ate vicinity,  a  condition  that  appears  to  occur  especially  when  the  roseolse 
have  been  profuse  and  have  persisted  for  a  considerable  time.  I  have 
now  and  then  observed  in  children  and  young  adults  that  the  lenticular 
efflorescence,  instead  of  simply  subsiding  and  fading,  is  converted  at  its 
center  into  a  minute  conical  vesicle,  whose  contents  soon  become  turbid 
and  undergo  desiccation.  This  process  takes  place  in  the  supei-ficial 
layers  of  the  epidermis,  so  that  a  scar  is  never  left. 

It  is  a  noteworthy  fact  that  the  roseolse  themselves,  representing,  as  we 
have  seen,  a  purely  hyperemic  exanthem,  practically  never  become  hem- 
orrhagic even  thi-oudiout  the  course  of  their  further  existence.  I  believe 
that  I  have  observed  this  in  but  a  few  cases  among  thousands.     Only  in 


SYMPTOMS  AND   COMPLICATIONS.  127 

the  extremely  rare  cases  of  hemorrhagic  typhoid  fever,  such  as  have  been 
described  especially  by  Miirchison  and  Licbermeister,  do  some  of  the 
roseolae  become  hemorrhagic,  together  with  extensive  bloody  suffusion 
of  other  portions  of  the  skin  free  from  roseolse.  From  this  condition 
must  be  sharply  differentiated  the  insignificant  hemorrhages  into  the 
hair-follicles  of  the  legs,  which  are  not  at  all  rarely  observed  during 
convalescence  from  severe  attacks  of  typhoid  fever,  in  association  with 
the  development  of  edema  about  the  ankles. 

Recently,  attention  has  been  directed  to  a  study  of  the  blood  obtained 
from  the  rose-spots,  not  alone  because  of  the  theoretic  significance,  but  also 
because  of  the  possible  diagnostic  value.  Neuhaus '  claims  to  have  found 
the  Eberth  bacillus  in  more  than  half  of  the  cases  examined  by  him,  and 
also  Riitimyer '  was  equally  successful  iu  1  case.  In  a  large  number  of 
observations  directed  to  this  point  I  have  obtained  only  negative  results,  as 
have  also  other  observers,  as,  for  instance,  Frankel  and  Simmonds,  Seitz, 
Janowski,  Chantemesse,  and  Widal. 

Since  the  above  was  written,  typhoid-bacilli  have  been  obtained  from  the 
rose-spots  by  Thiemich='  in  3  out  of  7  cases  examined ;  by  Neufeld,'  13  out 
of  14  cases  ;  Curschmann,^  14  out  of  20  cases  ;  Richardson,^  5  out  of  6  cases  ; 
Scholz  and  Krause,'  14  out  of  16  cases.  The  method  used  in  most  of  these 
cases  consisted  in  incising  the  spot,  collecting  a  drop  of  the  exuding  blood,  and 
moculating  this,  together  with  some  of  the  tissue-scrapings,  into  fluid  media. 

R  Frankel,*  by  excising  the  spots,  placing  them  in  bouillon,  and  so 
allowmg  the  bacteria  to  multiply  in  the  tissue,  has  been  able  to  demonstrate 
the  bacteria  in  sections.  From  all  of  this  work  it  seems  probable  that  a 
collection  of  the  bacteria  in  the  blood  of  the  rose-spots  always  occurs. 

The  roseolae  of  typhoid  fever  are  absolutely  distinct  from  the  exan- 
them  of  typhus  fever.  The  latter  is  made  up  of  true  macules,  and  not 
papules.  At  most  they  may  be  slightly  raised  for  a  short  time  immedi- 
ately after  their  appearance.  In  form  they  are  not  so  regular  as  the 
roseolae,  and  their  borders  are  diffuse  and  indistinct.  Purely  hyperemic 
and  pale  red  at  first,  they  soon  become  hemorrhagic  from  the  center 
outward,  so  that  in  contradistinction  from  the  typhoid  roseola  they  can 
only  in  part  be  made  to  disappear  on  pressure.  Their  color  then 
becomes  coppery  red  or  dull  bluish  red  and  even  dirty  livid.  They 
leave  traces,  in  the  form  of  greenish-yellow  or  brownish  spots  (blood- 
pigment),  far  into  convalescence.  The  exanthem  of  typhus  fever,  in 
addition,  appears,  on  the  average,  somewhat  earlier  than  the  typhoid 
roseolae,  namely,  from  the  third  to  the  fifth  day  of  the  disease.  It 
never  appears  in  crops,  but  all  at  the  same  time,  so  that  in  from 

^  Berlin.  Uin.  Woch.,  1886,  Nos.  6  and  44. 

■^  GentralU.f.  klin.  Med.,  1887,  No.  9.         3  Deidsch.  med.  Woch.,  1895. 

*  Zeit.f.  Hyg.,  Bd.  xxx.  5  Munch,  med.  Woch.,  1899.  No.  48 

«  Phila.  Med.  Jour.,  1900,  vol.  v.  '  Zeit.f.  klin.  Med.,  Bd.  Ixi. 

s^eii!./.  IZy^.,  Bd.  xxxiv. 


128  TYPHOID  FEVER. 

twenty-four  to  forty-eight  hours,  on  the  tnerage,  the  eruption  is  likely  to 
have  attained  its  definite  development  and  distribution.  I  have  never 
observed  m  connection  with  the  exanthem  of  typhus  fever  the  recrudes- 
cences that  constitute  the  rule  in  cases  of  typhoid  fever.  The  distribu- 
tion of  the  exanthem  of  typhus  fever  also  differs  in  a  most  distinctive 
manner  from  that  of  typhoid  fever.  Although  in  both  the  trunk  is 
involved  first  and  preferably,  the  eruption  of  typhus  fever  extends  not 
rarely  to  the  face,  and  especially  to  the  extremities.  In  fact,  it  is  often 
not  less  dense  upon  these  than  upon  the  trunk,  and  it  is  a  characteristic 
feature,  besides,  that  the  exanthem,  in  marked  contrast  to  the  distribu- 
tion of  the  typhoid  roseol£e,  is  likely  to  be  especially  marked  upon  the 
forearms  and  the  dorsa  of  the  hands,  while  those  parts  of  the  extremi- 
ties nearest  the  trunk  are  not  involved  in  greater,  but  often  even  in 
less,  degree. 

Urticaria  and  papular  exanthems  (Griessinger)  may  be  mentioned  as 
rarities  in  the  course  of  typhoid  fever.  I  have  noted  urticaria  only  in 
exceptional  instances  at  Hamburg,  and  in  0.3  per  cent,  of  the  cases  at 
Leipsic.  Jenner,  Raymond,  LeMaigre,  and  others  report  the  presence 
of  scarlatiniform  eruptions,  and  also  of  measly  eruptions,  which  appeared 
durmg  the  second  and  also  the  third  week,  and  were  by  no  means  eva- 
nescent. Apart  from  the  initial  varieties  of  rash  previously  mentioned, 
I  have  observed  nothing  of  the  kind,  and  am  inclined  to  the  view  that 
at  least  a  portion  of  these  eruptions  are  to  be  considered  as  drug-exan- 
thems,  and  this  seems  the  more  probable,  as  for  a  long  time  it  was  cus- 
tomary to  treat  typhoid  fever  with  large  doses  of  antipyretic  drugs, 
capable  often  of  inducing  varied  exanthems.  Peculiar  bluish,  livid 
spots,  varying  in  size  from  that  of  a  lentil  to  a  half-inch  in  diameter, 
have  been  described  by  the  older  French  observers — a  most  complete 
description  has  been  given,  for  instance,  by  Trousseau — as  a  frequent 
lesion  of  the  skm.  They  have  been  designated  taches  bleuatres  or  as 
typhoid  peliomata,  and  were  considered  by  Murchison  and  Trousseau  as 
almost  specific  and  prognostically  favorable  signs  of  the  disease.  The 
famous  typhoid  peliomata  came  to  an  ignominious  end  :  they  were  found 
to  be  due  to  pediculi. 

The  eruption  designated  miliaria  crystallina  is  worthy  of  more 
careful  consideration.  It  occurs  much  more  frequently  in  cases  of 
typhoid  fever  than  in  those  of  other  infectious  diseases. 

Although  I  cannot  agree  with  Louis,  who  was  inclined  to  attach 
specific  significance  to  the  eruption,  I  should  not  fail  to  mention  that  of 
150  successive  cases  of  typhoid  fever  examined  for  the  presence  of  sudam- 
ina,  these  were  found  in  more  or  less  marked  degree  in  98.     With  regard 


SYMPTOMS  AND   COMPLICATIONS.  129 

to  the  other  infectious  diseases,  I  may  state  that  I  have  observed  crystalline 
miliaria  rarely  in  cases  of  measles  and  scarlet  fever,  and  more  frequently 
in  cases  of  acute  septicemia  and  typhus  fever. 

The  eruption  of  miliaria  generally  appears,  on  the  average,  later  in 
the  course  of  typhoid  fever  than  the  roseolsB — from  the  middle  or  the 
end  of  the  second  to  the  end  of  the  third  or  the  beginning  of  the  fourth 
vreek.  It  appears  in  the  well-known  form  of  roundish,  distinct  vesicles, 
varying  in  size  from  that  of  the  head"  of  a  pin  to  that  of  a  lentil,  and 
of  which,  if  the  eruption  be  well  developed,  two  or  more  generally 
coalesce  to  form  larger  efflorescences  of  irregular  contour.  Filled  with 
contents  of  water-like  clearness,  they  cover  the  skin  like  drops  of  dew. 
The  imaginative  Trousseau  and  Louis  compared  them  with  tears.  On 
account  of  the  colorless  contents  and  the  exceedingly  thin  covering  of 
the  vesicles,  they  may  readily  be  overlooked  with  imperfect  illumination. 
Not  rarely  they  are  first  appreciated  on  palpation,  if  the  palm  of  the 
hand  is  passed  over  the  parts  occupied  by  them.  They  can  be  seen 
especially  well  if  viewed  with  oblique  light.  The  content  of  the 
sudamina  I  have  always  found  feebly  acid  or  neutral,  and  never  alka- 
line. It  never  becomes  purulent,  and  disappears  by  absorption  or  rupt- 
ure of  the  vesicles,  after  which,  if  they  were  numerous,  branny 
desquamation  of  the  skin  persists  for  a  few  days.  Miliaria  appear 
earliest  and  in  greatest  profusion  upon  the  lower  portion  of  the  abdomen, 
extending  from  this  situation  to  the  chest  and  the  lateral  portions  of  the 
neck,  as  well  as  to  the  thighs.  The  exanthem  is  usually  scanty  upon 
the  forearms  and  the  legs.  I  have  observed  it  but  rarely  upon  the 
hands  and  the  dorsa  of  the  feet,  and  never  upon  the  face. 

Herpetic  eruptions  are  so  rare  in  cases  of  typhoid  fever  that  I  con- 
sider this  circumstance  of  diagnostic  importance  in  the  differentiation 
from  other  infectious  diseases.  Every  experienced  physician  is  aware 
of  the  frequent  association  of  this  variety  of  eruption  with  pneumonia, 
malaria,  cerebrospinal  meningitis,  influenza,  and  typhus  fever.  During 
the  epidemic  of  typhus  fever  at  Berlin  in  1879  I  observed,  for  instance, 
herpes  in  5  per  cent,  of  all  cases.  When  present  at  all,  I  have  found 
herpes  in  cases  of  typhoid  fever  especially  upon  the  face,  and  here  in  the 
usual  situations.  It  then  appeared  principally  in  the  first  week,  at  times 
even  before  the  appearance  of  the  roseolous  eruption,  and  far  less  com- 
monly at  a  later  period.  In  cases  of  convalescence  from  tj-phoid  fever  I 
have  noted  it  in  a  few  instances  upon  the  trunk  and  the  extremities, 
in  the  form  of  intercostal  and  femoral  herpes.  The  observation  of 
Gerhardt  and  Seidel,  that  herpes  is  more  frequent  m  children  than  in 
adults,  is  not  in  accord  with  my  own  experience. 


130  TYPHOID  FEVER. 

The  occurrence  of  furuncles,  abscesses,  phlegmons,  and 
erysipelas  in  the  course  of  typhoid  fever  is  quite  serious.  While 
phloguious  aud  eiysipelas  are  less  common  and  to  be  considered  rather 
as  accidental  conditions,  often  in  connection  ^^^th  sliglit  injuries,  bed- 
sores, etc.,  furuncles  and  small  cutaneous  abscesses  are  more  common 
and  of  unpleasant  significance,  especially  during  the  period  of  defer- 
vescence and  of  convalescence.  After  severe  attacks  of  typhoid  fever, 
convalescence  may  be  greatly  protracted  by  them.  I  have  even  observed 
life  threatened  directly  in  debilitated  individuals.  I  have  encountered 
cases  in  which  from  60  to  80  larger  or  smaller  furuncles  and  abscesses 
developed  successively  upon  the  skin  and  had  to  be  incised.  The  most 
frequent  seat  of  furunculosis  is  the  dorsal  aspect  of  the  trunk,  especially 
the  gluteal  region.  Then  the  chest  and  the  abdomen,  the  thighs,  and 
the  arms  are  preferably  attacked.  Fiuiinculosis  of  the  skin  appears  to 
occur  with  especial  frequency  at  times  when  typhoid  fever  is  vigorously 
treated  with  frequently  repeated  and  exceedingly  cold  baths.  Since  I 
have  abandoned  tliis  method  of  treatment  furunculosis  has  become  less 
common  among  my  patients.  To  be  separated  from  tliis  condition  are 
the  abscesses  of  the  skin  that  have  been  obsei'ved  as  associated  mani- 
festations of  a  complicating  pyemia,  with  suppuration  of  joints  and 
purulent  metastases  in  internal  viscera.  Fortunately,  these  occurrences 
are  rare. 

Bed-sores,  which  formerly  were  one  of  the  most  dreaded  sequels 
of  typhoid  fever,  have  become  an  uncommon  manifestation  with  the 
development  of  a  rational  mode  of  treatment  and  of  nursing  of  the 
patient.  Even  in  severe  cases  of  long  duration  they  can  generally  be 
avoided  or  aborted  in  their  early  stages.  Apart  from  exceptional  condi- 
tions, the  occurrence  of  a  bed-sore  in  private  practice,  as  well  as  in  the 
hospital,  is  a  reproach  to  the  physician  and  the  attendants. 

In  the  epidemic  of  typhoid  fever  at  Hamburg  in  1^86-87  I  observed 
bed-sores  in  1.9  per  cent,  and  in  Leipsic  in  only  1  per  cent,  of  the  cases.  In 
connection  with  these  small  figures  it  must  additionally  be  taken  into  con- 
sideration that  disproportionately  many  severe  cases,  often  in  a  neglected 
state,  are  sent  to  the  hospitals. 

The  seat  of  predilection  for  bed-sores  is,  as  is  well  known,  the  lower 
sacral  and  the  gluteal  region  ;  less  commonly  the  heels,  the  scapular 
region,  that  of  the  spinous  processes  of  the  vertebrae,  as  well  as  the 
occipital  region,  are  involved.  Apart  from  exceedingly  severe  cases 
complicated  by  septic  or  other  equally  grave  conditions,  in  which  bed- 
sores may  appear  as  early  as  from  the  eighth  to  the  fourteenth  day,  the 
affection  is  always  a  late  manifestation  of  the  disease.     It  persists  from 


SYMPTOMS  AND   COMPLICATIONS.  131 

the  latter  portion  of  the  febrile  stage  into  the  period  of  convalescence, 
which  it  often  aggravates,  complicates,  and  protracts  extremely. 

Various  forms  of  bed-sores  can  be  distinguislied — a  fact  that,  it  may 
be  parenthetically  remarked,  is  not  sufficiently  appreciated  by  some 
observers.  The  simplest  and  most  common  is  that  induced  by  pressure 
of  the  usually  soiled  body  upon  the  bed.  It  generally  begins  in  the 
sacral  region  and  on  the  most  prominent  points  of  the  nates,  with 
diffuse  circumscribed  redness,  with  or  without  ecchymoses.  Then 
exfoliation  of  the  epidermis  occurs,  with  exposure  of  the  corium,  which 
bleeds  readily  and  is  already  somewhat  discolored.  Meanwhile  there 
develops  a  red  line  of  demarcation,  followed  by  yellowish  discoloration 
and  desiccation  of  the  affected  part,  with  the  formation  of  a  parchment- 
like slough,  which,  after  a  varying  time,  is  thrown  oif  as  a  whole  or  is 
detached  in  threads  or  is  removed  artificially.  Even  with  the  first 
slough,  which  also  may  be  discolored,  soft,  and  smeary,  the  skin  and 
subcutaneous  connective  tissue  down  to  the  muscle  may  be  exfoliated. 
In  especially  severe  and  particularly  long-neglected  cases  the  destruction 
advances  more  and  more  deeply  down  to  the  bone.  This  also  may 
undergo  necrosis  and  subsequently  be  exfoliated,  and  I  have  in  several 
instances  observed  the  sacral  canal  to  be  opened. 

Another  variety  of  bed-sore,  which,  by  reason  of  its  mode  of  origin, 
may  appear  simultaneously  in  several,  even  in  numerous  places,  develops 
in  connection  with  ecthyma  and  eczematous  and  furunculous  eruptions 
in  the  gluteal  and  sacral  regions.  It  gives  rise  to  small  superficial 
ulcers  of  irregular  outline,  confluent  at  various  points,  and  it  is  especially 
the  result  of  want  of  cleanliness  in  the  care  of  the  patient. 

A  third  variety  I  would  designate  the  subcutaneous  bed-sore.  It  does 
not  always  develop  in  places  that  are  most  subjected  to  pressure  in  the 
recumbent  posture,  but  it  occurs  rather  below  the  gluteal  region,  prefer- 
ably over  the  lowermost  portion  of  the  sacrum  and  the  coccyx,  in  the 
depth  of  the  anal  fold.  Developing  almost  exclusively  in  cases  of 
especial  severity,  this  variety  of  bed-sore  is  indicative  of  a  profound 
constitutional  disturbance  of  nutrition.  It  is  that  variety  that  may  be 
unavoidable  even  with  the  most  scrupulous  care.  In  the  generally 
profoundly  stuporous  patients,  who  exhibit  no  manifestation  of  pain,  it 
occasionally  acquires  considerable  extent  without  the  attention  of  the 
attendants  being  attracted  to  it,  this  occurring  especially  because  at  the 
beginning,  in  spite  of  considerable  progressive  deep-seated  destruction, 
the  skin  exhibits  slight  or  no  alteration.  When  I  have  been  able  to 
follow  the  process  more  closely,  a  dense,  at  times  remarkably  msensi- 
tive,  infiltration  appeared  beneath  the  unaltered  or  somewhat  reddened, 


132  TYPHOID  FEVER. 

edematous  skin.  The  skin  generally  then  became  gradually  discolored 
bluish  red  or  even  greenish  yellow  from  imbibition  of  hemoglobin. 
Meanwhile  the  indurated  area  has  undergone  sottenmg  to  the  degree 
of  distinctly  demonstrable  fluctuation,  and  now  discharge  of  difiluent, 
putrid,  dirty  pits  takes  place  from  a  number  of  small  irregularly 
distributed  openings,  unless  an  incision  has  been  previously  made. 
It  is  most  characteristic  of  this  variety  of  bed-sore  that  the  destruction 
is  far  more  extensive  deeply  than  would  be  suspected  from  the  extent 
of  the  palpable  infiltration  or  the  thinning  or  discoloration  of  the  skin. 
If  extensive  incisions  have  been  made,  or  if  the  thmued  skin  has  been 
permitted  to  exfoliate  spontaneously,  the  necrotic  cellular  tissue  may  be 
removed  with  the  pus  in  large,  friable,  discolored  shreds.  It  is  dis- 
tinctive of  this  variety  further  that  the  destructive  process,  however 
extensive  it  may  be,  rarely  extends  beyond  the  subcutaneous  connective 
tissue  into  the  depth.  Its  main  characteristic  is  subcutaneous  necrosis 
and  suppurative  softening  of  the  cellular  tissue. 

Naturally,  a  distinction  is  not  possible  in  practice  between  the  several 
varieties  of  bed-sores  described  such  as  has  I)een  made  for  purposes  of 
completeness  in  presentation.  Often  the  diflerent  varieties  are  merged 
into  one  another  or  appear  simultaneously  or  successively  in  the  same 
individual.  Circumscribed  gangrene  of  the  skin  in  other  situations  than 
those  threatened  by  bed-sores  occurs  with  extreme  rarity  and  only  in  greatly 
reduced  individuals,  and  it  is  then  of  ominous  significance.  Occurring 
here  and  there  entirely  without  obvious  cause,  it  appears  at  other  times 
on  parts  of  the  skin  that  have  been  subjected  to  accidental  traumatism  or 
to  the  effects  of  measures  employed  for  therapeutic  purposes.  Thus,  I 
have  observed  in  situations  where  previously  a  mustard-plaster,  a  dry  cup, 
or  some  other  so-called  resuscitating  agent  had  been  applied  circumscribed 
gangrene  of  the  skin  in  an  area  of  corresponding  form  and  extent. 
Also,  iu  situations  that  had  been  exposed  for  an  excessively  long  time  to 
the  action  of  a  poultice  or  an  ice-bag,  I  have  exceptionally  observed  the 
development  of  cutaneous  gangrene — naturally  not  including  acute  bums 
or  freezing.  The  occurrence  of  true  noma  as  a  sequel  of  typhoid  fever 
is  so  frequently  mentioned  by  earlier  writers  that  I  am  inclined  to 
doubt  whether  the  diagnosis  of  that  condition  was  always  correct. 
Among  the  large  number  of  cases  that  have  come  under  my  observation 
I  have  only  once  seen  an  affection  in  a  child  under  the  most  wretched 
conditions  that  could  be  considered  as  noma. 

A  word  may  be  added  with  regard  to  changes  in  the  hair  and  the 
nails.  Falling  out  of  the  hair  is  well  known  and  so  common  that 
scarcely  any  typhoid  patient  is  wholly  exempt  therefrom.     It  occurs 


SYMPTOMS  AND   COMPLICATIONS.  133 

almost  exclusively  upon  the  scalp,  less  commonly  the  beard,  scarcely 
ever  upon  the  pubes  or  in  the  axillae.  Two  cases  of  complete  alopecia, 
with  loss  absolutely  of  all  the  hair  of  the  body,  that  I  have  observed 
during  convalescence  from  typhoid  fever  were  perhaps  unique,  and  the 
lesion  was  scarcely  related  to  the  original  disease.  The  loss  of  hair 
usually  begins  during  the  last  week  of  the  disease,  and  continues  far 
into  convalescence  or  even  up  to  the  time  when  the  patients  resume 
their  usual  occupations.  The  patients  can  be  assured  with  comparative 
certainty  4hat  they  will  gradually  regain  their  hair  without  artificial  aid. 
Generally,  the  hair  begins  to  be  replaced  in  certain  parts  while  it  is  still 
falling  out  in  other  situations.  The  new  hair  is  generally  thicker,  tougher, 
and  is  lusterless.  Upon  transverse  section  it  is  often  for  some  distance, 
rarely  throughout  its  entire  length,  not  round,  but  elliptic — a  circum- 
stance 'that  is  probably  associated  with  the  curliness  almost  constantly 
present. 

After  protracted  severe  attacks  of  typhoid  fever  the  nails  are  not 
rarely  thin,  lusterless,  and  friable.  Only  in  one  instance  have  I  observed 
them  to  be  completely  thrown  off  from  the  fingers,  and  in  part  also  from 
the  toes,  and  this  occurred  in  one  of  the  cases  of  total  alopecia  previously 
mentioned.  Further,  slight  changes  in  the  finger-nails,  far  less  com- 
monly in  the  toe-nails,  are  frequently  observed  even  after  cases  of  typhoid 
fever  of  moderate  severity  in  young  persons,  and  to  which  A.  Vogel  ^ 
called  attention  many  years  ago.  These  consist  in  transverse  gutter- 
like depressions  and  grooves  in  the  body  of  the  nail,  which  occur 
in  the  stage  of  most  profound  depression  of  the  bodily  nutrition,  of 
which  it  is  the  local  expression.  It  is  interesting  to  note  that  behind 
this  depression  or  groove  there  frequently  occurs  a  more  or  less  wide, 
wall-like  thickenmg  and  elevation  of  the  nail,  which  evidently  is  due  to 
the  improved,  oflen  unusually  increased,  nutritive  conditions  during* 
convalescence. 

COURSE   OF    THE  FEVER;    ESPECIAL    CONDITION  OF    THE   BODY- 
TEMPERATURE. 

The  alterations  in  body-temperature  constitute  one  of  the  best- 
studied  chapters  of  typhoid  fever.  Since  the  determination  by  Wun- 
derlich  of  the  typical  course  of  the  temperature-curve,  its  observation 
has  become  one  of  the  most  important  diagnostic  and  prognostic  aids. 
Wunderlich's  conclusions  are,  on  the  whole,  still  applicable.  They  con- 
stituted the  starting-point  of  further  extensive  investigations  on  the 
part  of  his  pupils  and  successors,  and  will  undoubtedly  constitute  the 

'  Deutsch.  Arch.f.  klin.  Med.,  Bd.  vii.,  S.  333  and  following. 


134  TYPHOID  FEVER. 

basis  for  subsequent  studies  of  the  febrile  course  of  typhoid  fever. 
Without  doubt,  the  temperature-variations  in  tlie  course  of  typhoid  fever 
are  to  be  considered  as  the  expression  of  bacterial  intoxication  and  the 
resulting  general  changes  in  the  body  and  the  viscera,  in  connection 
with  which,  naturally,  individual  conditions,  and  especially  the  physical 
state  of  the  patient  before  the  attacks,  are  co-operative  in  the  fullest 
degree.  A\'ith  the  conception  of  the  fever  as  the  expression  of  the 
specific  morbid  conditions  taking  place  within  the  body,  the  observa- 
tion made  by  AVunderlich  and  his  pupils,  that  the  various  anatomic 
stages  of  the  typhoid  disease-process  are  reproduced  in  approximately 
tj'pical  cases  in  the  form  of  the  curve,  is  in  accord.  Wunderlich  even 
added,  with  perfect  justice,  that,  e^•en  in  cases  pursuing  a  less  regular  or 
a  complicated  course,  certain  distinctive  features  of  the  typical  curve 
passed  through  the  febrile  course  like  a  red  line.  The  statement  of 
Wunderlich,  that  far-reaching  diagnostic  conclusions  can  be  formed 
fi'om  the  curve  and  from  certain  parts  of  it,  is  based  upon  these  facts. 

The  scientific  study  of  the  fever-curve  occupied  a  lara'e  number  of  clin- 
icians during  Wunderlicb's  ^  time  and  for  many  years  afterward.  Among 
Wunderlich's  pupils  who  deserve  especial  credit  in  this  connection,  Thier- 
felder/  Uhle,^  Fiedler/  Wacbsmutb/  and  Thomas''  should  be  mentioned. 

An  excellent  summary,  based  upon  personal  experience,  has  been  made 
by  Griessinger.'  The  publications  of  Baumler,*^  Liebermeister,*  Jiirgeuseu,'" 
Ziemssen,''  and  Immermann  ^'^  constituted  further  a  mine  of  important  ob- 
servations bearing  upon  the  fever  of  typhoid. 

The  average  duration  of  the  febrile  period  in  a  moderately  severe  or 
severe  case  of  typhoid  fever  is,  as  has  been  mentioned,  from  three  to 
four  weeks.  Generally,  the  schematic  representation  of  the  temperature- 
curve  is  based  upon  a  duration  of  four  weeks,  the  character  of  the  cun^e 
being  established  for  each  individual  week.  It  appears  better  to  me  to 
divide  the  disease  into  three  or  four  parts,  and  appreciate  from  the  outset 

1  Wunderlich,  Arch.  f.  physiol.  Heilk.,  Bd.  xvi.,  1857,  and  Bd.  xvii..  1858. 
Arch.  d.  Heilk.,  Bd.  iii.,  1861.    Die  Thermometrie  am  Krankenbefie,  2d  ed.,  Leipsic. 

«  Arch.f.  physiol.  Heilk.,  Bd.  xiv.  ^  Ibid.,  Bd.  xviii. 

*  Arch.d.  Heilk.,  Bd.  iii.  ^  Ibid.,  Bd.  iv. 

6  Ibid.,  Bd.  v.,  S.  3.S1  u.  527.  '  Doc.  cit. 

®  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  iii. 

^Collected  Works.  "  Typhoid  Fever "  in  Zie7nssen's  Handbuch.  Liebermeister 
and  Hagenhach,  Beobachiungen  und  Versuche  uber  die  Anwendung  des  kalten  Wassers 
bei  -fieberhaften  Krankheiten,  Basle,  1868. 

"  Klinische  sindien  iiber  die  Behandlunq  des  Abdominalfyphus  7nit  kalten  Wasser, 
1886.      "Die  leichteren  Formen  des  Typhus. ''  Volkmann''s  Sammlung  klin.   Vortr. 

"  In  a  number  of  smaller  personal  publications  and  .similar  publications  by  his 
pupils. 

^''  Ziemssen  and  Immermann,  Die  Kaltwasserbehatidlung  des  Typhus  abdominalis, 
1870. 


SYMPTOMS  AND  COMPLICATIONS. 


135 


that  these  are  by  no  means  equally  long  and  in  the  individual  case  alike, 
but  that  each  may  be  shorter  or  longer,  extended  or  abbreviated. 

We  shall  now  describe,  somewhat  schematically,  as  is  unavoidable  in 
a  systematic  presentation,  the  form  of  the  temperature -curve  for  a 
moderately  severe  or  severe  case  of  typhoid  fever  of  typicsal  course. 
Then  the  variations  in  the  course  of  the  curve  under  special  individual 
and  temporal  conditions  will  be  considered,  and  finally,  it  will  have  to  be 
pointed  out  how  varied  its  separate  parts  may  be  under  varying  circum- 
stances. Before  describing  the  curve  of  the  actual  febrile  stage,  a  few 
remarks  may  be  made  concerning  the  state  of  the  body-temperature 
during  the  period  of  incubation,  namely,  the  time  when  the  typhoid 
process  is  unattended  with  either  objective  or  subjective  symptoms,  or 


Period  of  inoiibation. 


First  day  of  fever. 


Fig.  8.— Temperature-curve  from  a  case  of  typhoid  fever  in  a  man,  twenty-one  years  old.  Noso- 
comial infection  during  convalescence  from  a  severe  febrile  attack  of  rheumatic  polyarthritis. 
Even  before  the  beginning  of  the  characteristic  curve  of  the  first  week  of  typhoid  fever,  the 
subnormal  temperature  following  recovery  from  polyarthritis  rises  to  the  average  normal  level 
and  exhibits  a  number  of  fluctuations  more  than  usually  marked. 

before  transitory,  ill-defined,  and  varying  disturbances  and  complaints  are 
present.  In  general,  this  stage  is  free  from  true  febrile  manifestations. 
If,  however,  careful  observation  be  made  in  times  of  epidemics,  particu- 
larly if  the  temperature  of  apparently  still  healthy  predisposed  relatives 
of  the  patient  be  taken  regularly,  if  cases  are  observed  that  are  admitted 
into  the  hospital  during  the  period  of  incubation  with  an  indefinite 
diagnosis,  or  if  nosocomial  attacks  are  thoroughly  studied  from  the 
outset,  the  course  of  the  temperature-curve  in  the  period  of  incubation 
will  show  in  not  a  few  that  something  is  taking  place  within  the  body. 
In  a  certain  proportion  of  the  individuals  in  question  it  will  be  found 
that,  without  actual  febrile  elevation  of  temperature,  a  more  marked 
variation  in  the  daily  curve  takes  place  than  under  physiologic  condi- 


136 


TYPHOID  FEVER. 


tions ;  the  temperature  may  be  somewhat  lower  in  the  morning,  and  a 
few  tenths  of  a  degree  higher  in  the  evening,  than  was  observed  in  the 
patient  while  in  a  state  of  health.  In  other  patients  a  temperature  of 
38°  C.  or  somewhat  higher  is  occasionally  attained  toward  midday  or 
evening,  either  spontaneously  or  more  frequently  after  physical  and 
mental  exertion.  In  those  convalescent  from  other  febrile  diseases  w'ho 
exhibit  subnormal  temperature  in  consequence  of  exhaustion,  the  body- 
temperature  rises  somewhat,  to  the  normal  of  the  individual,  as  they 
enter  upon  the  stage  of  incubation  of  the  attack  of  typhoid  fever,  and 
under  such  conditions  it  exhibits  at  times  unusual  fluctuations  between 
morning  and  evening  (Fig.  8). 

This  instability  of  the  temperature-curv^e  during  the  period  of  incu- 
bation is  quite  generally  associated  with  considerable  variability  in  the 
pulse,  W'hich  on  slight  provocation  increases  suddenly  in  frequency,  and 
particularly  in  the  evening  is  often  much  more  rapid  than  it  is  during 
health. 


I   believe  that  greater  importance  than  is  commonly  given  should  be 
attached  to  the  pulse-temperature  ratio  during  the    period  of  incubation. 

Careful  observation  of  this 
ratio  at  this  time  may  occa- 
sionally lead  the  trained  ob- 
server in  the  right  direction. 
Invariably,  and  almost  in  a 
typical  manner,  it  occurs  re- 
peatedly that  dwellers  in  a 
hospital,  for  instance,  servants, 
laborers,  mechanics,  who  ex- 
hibit only  general  symptoms 
and  apparently  are  free  from 
fever,  are  sent  to  the  hospital 
with  an  indefinite  diagnosis, 
and  sometimes  with  a  suspi- 
cion of  simulation.  Under 
such  circumstances  no  especial 
organic  alteration  will  in  fact 
be  found,  artd  only  on  careful 
observation  of  the  abnormally 
marked  fluctuation  in  the 
daily  curve  and  the  instability 
of  the  pulse  will  attention  be 
awakened  to  the  fact  that  im- 
portant processes  are  taking  place  in  the  body.  The  experienced  clinician 
will  then,  among  other  things,  think  of  the  incubation-stage  of  typhoid 
fever,  and  recommend  rest. in  bed  with  a  restricted  diet.  Often  the  occur- 
rence of  repeated  chilliness  at  the  beginning  of  the  febrile  stage  and^  the 
subsequent  characteristic  elevation  of  temperature  will  show  how  justified 
was  the  caution  observed  (Fig.  9). 


KiG.  9,— Temperature-curve  from  a  case  of  typhoid 
fever  in  a  waiter,  twenty-six  years  old,  admitted  with 
a  suspicion  of  simulation.  Durina:  the  first  nine  days 
there  was  no  febrile  elevation  of  temperature,  but  only 
abnormally  wide  daily  fluctuations.  On  the  tenth  day 
the  febrile  period  of  a  moderately  severe  attack  of 
typhoid  fever-  pursuing  a  regular  course  set  in. 


SYMPTOMS  AND  COMPLICATIONS.  137 

In  the  first  week  of  fever  the  elevation  of  temperature  attains  the 
definitive  height  of  the  febrile  period  in  general,  or  it  may  rise  even 
higher.  The  mode  of  ascent  of  the  temperature-curve,  in  contradistinc- 
.tion  from  that  of  many  other  infectious  diseases,  as,  for  instance,  typhus 
fever,  pneumonia,  and  variola,  is  generally,  in  the  case  of  typhoid  fever, 
more  gradual.  Usually,  the  ascending  movement  of  the  curve  continues 
for  from  three  to  five  days ;  less  commonly  the  entire  first  week  is  occu- 
pied by  it.  This  mode  of  protracted  ascent  is  in  itself  of  importance  in 
differential  diagnosis.  In  addition,  the  remarkably  uniform,  character- 
istic course  of  this  portion  of  the  curve  in  detail  is  characteristic.  The 
temperature  rises  in  such  a  manner  that  it  is  regularly  from  0.6°  to 
1.0°  C.  higher  in  the  evening  than  on  the  preceding  evening,  while  it 
exhibits  each  morning  a  reduction  of  from  0.4°  to  0.6°  C,  so  that  it  does 
not  become  as  low  as  it  was  on  the  previous  day.  The  form  of  the 
ascent  is,  in  other  words,  step-like.  If,  in  this  way,  on  the  evening 
of  the  third  to  the  fifth  day,  or  in  markedly  protracted  cases  as  late  as 
the  sixth  or  the  seventh  day,  the  definitive  height  of  the  temperature  is 
reached  at  40°  C.  and  above,  even  41  °  C,  the  fever  then  remains  continued 
for  a  week  or  even  longer,  not  rarely  for  a  week  and  a  half  or  t^vo 
weeks  ;  40°  C.  and  above  in  the  evening,  and  toward  morning  a  reduction 
not  exceeding  the  physiologic  variation. 

In  isolated  instances  slighter  daily  variations  than  the  normal  may 
take  place  either  for  a  few  days  or  throughout  the  entire  febrile  stage,  so 
that  the  course  of  the  temperature  closely  approximates  that  of  a  con- 
tinued fever  in  the  true  sense.  This  feature  is  observed  almost  always 
in  severe  cases.  Stated  in  detail,  variations  only  of  from  0.3°  to  0.5°  C. 
occur,  or  even  less,  between  the  highest  evening  and  the  morning  tem- 
perature, and  at  times  no  variation  at  all  is  observed  for  several  days. 
In  cases  of  such  especial  severity  the  average  temperature  also  is  gener- 
ally higher.  It  is  in  such  cases  that  the  temperature  reaches  41  °  C.  and 
above,  and  in  which,  if  the  patient  does  not  previously  succumb  to  the 
disease,  the  stage  of  continued  fever  may  be  extended  to  two  whole 
weeks  and  even  more.  Cases  setting  in  with  such  severity  sometimes 
acquire  a  more  favorable  aspect  after  the  first  week  of  the  continued 
fever  in  so  far  that  the  temperature-curve  during  the  second  week 
declines  to  a  somewhat  lower  level,  although  the  slight  degree  of  varia- 
tion persists  (Fig.  10). 

That  period  in  which  the  continued  fever  or  the  remittent  continued 
fever  becomes  more  markedly  remittent  or  even  intermittent  is  generally 
designated  the  third  febrile  period.  This  first  manifests  itself  by  the  cir- 
cumstance that  the  evening  temperature  still  remains  at  its  usual  height, 


138 


TYPHOID  FEVER. 


or  approximately  so,  while  the  morning  reduction  becomes  much  more 
marked,  from  1.5°  to  2°  C  and  more.  If  the  disease  pursue  a  mild 
course,  such  remissions  may  make  their  appearance  as  etirly  as  the  mid- 
dle or  the  end  of  the  second  week,  while  in  more  marked  and  in  severe 
cases  the  bcgiiming  is  deferred  to  the  third  or  even  the  commencement 
of   the   Ibuith   week.     The   duratit)u   of   this   portion   of  the  curve  is 

variable :  from  three  to 
five  days,  rarely  longer. 
It  is  especially  this  por- 
tion of  the  curve  that  is 
most  frequently  shortened, 
ill  defined,  or  modified. 
It  may  even  remain  wholly 
undeveloped,  so  that  the 
stage  of  descending  curve 
follows  directly  that  of 
continued  fever  or  remit- 
tent continued  fever. 

The  stage  of  the  de- 
scending febrile  curve, 
which,  together  with  the 
preceding,  corresponds  to 
the  anatomic  process  of 
clearmg  up  of  the  last 
intestinal  ulcers  and  of 
progressive  cicatrization, 
is  generally  placed  be- 
tween the  end  of  the 
third  and  the  middle  of 
the  fourth  week.  From 
five  to  ten  and  even  four- 
teen days  then  elapse  be- 
fore the  normal  is  reached. 
In  this  stage,  which  is  often 
appropriately  designated 
that  of  steep  curves,  the  variations  in  temperature  are  often  more 
marked  than  in  the  previous  stage,  so  that  persistently  or  for  days 
variations  between  the  morning  and  evening  temperatures  may  be 
observed,  such  as  are  customarily  observed  in  the  course  of  diseases 
presenting  a  true  intermittent  type  of  fever.  Temperature- variations 
of  from  2°  to  2.5°  or  even  3°  C.   are  under  such  circumstances  not 


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SYMPTOMS  AND  COMPLICATIONS.  139 

uncommon.  Traube  has  with  propriety  pointed  out  the  similarity 
between  such  curves  and  those  of  certain  forms  of  pulmonary  tuber- 
culosis, and  has  accordingly  spoken  of  a  hectic  stage. 

In  special  cases  the  descent  of  the  curve  takes  place  in  such  a  man- 
ner that  the  morning  and  evening  temperatures  of  the  following  day  are 
lower  than  those  of  the  preceding  day.  At  the  same  time  the  decline  in 
the  morning  temperature  at  the  beginning  of  the  steep  curves  is  generally 
more  marked  than  the  height  of  the  evening  rise.  In  milder  cases 
pursuing  a  regular  course  it  may  be  mentioned  that  the  entire  coarse 
of  the  febrile  stage  may  not  rarely  be  compressed  into  a  period  of  three 
weeks,  with  the  characteristic  development  of  the  four  stages  of  the 
curve  as  just  described  for  the  severe  cases.  The  initial  stage  under  such 
circumstances  lasts  about  four  days  ;  the  succeeding  period  of  continued 
fever  continues  until  the  end  of  the  second  week,  thus  scarcely  more  than 
a  week ;  while  the  stage  of  intermittent  and  declining  curve  occupies  the 
last  days  of  the  second  and  the  third  week.  Such  a  course  may  be  illus- 
trated by  the  diagrammatic  chart  of  Wunderlich  (Fig.  11). 

We  are  indebted  to  the  extremely  careful  and  painstaking  observa- 
tions of  Thomas,^  Jiirgensen,^  Ziemssen  and  Immermann,^  and  others  for 
such  complete  knowledge  of  the  course  of  the  temperature  in  cases  of 
typhoid  fever  that  this  has  become  familiar  to  us  both  for  day  and  night 
and  from  hour  to  hour.  There  is  usually  an  uninterrupted  ascending 
tendency  of  the  curve  in  the  course  of  the  day,  so  that  in  the  late  hours 
of  the  afternoon,  generally  between  five  and  seven  o'clock,  the  maximum 
temperature  is  lilvely  to  be  reached.  From  this  point  on,  into  the  night 
and  until  morning,  there  is  a  gradual  decline,  so  that  the  temperature 
usually  reaches  its  lowest  point  between  six  and  nine  o'clock  in  the 
morning. 

The  temperature-curve  often  exhibits  a  noteworthy  deviation  in  per- 
sons who  by  reason  of  their  occupation  transform  night  into  day.  Thus, 
I  have  observed,  especially  in  bakers,  the  height  of  the  temperature  to 
occur  in  the  middle  of  the  night  or  even  at  an  early  hour  of  morning, 
and  the  decline  in  the  curve  toward  the  evening.  The  aged  and  children 
also  occasionally  exhibit  this  inverted  type  of  temperature. 

It  is  noteworthy  also  that  for  days  and  even  for  weeks  more  than  one 
elevation  of  temperature  may  take  place  in  the  course  of  twenty-four 
hours.     Not  at  all  rarely  there  are  two  such  elevations,  one  of  which 

1  Arch.  d.  Heilk. ,  1864. 

'''  Klin.  Studien  icber  die  Behandlung  des  Abdominaltyphus  mit  kaltem  Wasser, 
Leipsic,  1866. 

"  Die  Behandlung  des  Abdominaltyphus,  Leipsic,  1870. 


140 


TYPHOID  FEVER. 


generally  occurs  in  the  middle  of  the  day,  far  less  commonly  at  a  late 
hour  of  the  evenuig  or  during  the  night.  More  than  two  elevations  of 
temperature  in  the  twenty-four  hours  are  less  frequent.  Curves  with  two 
or  more  such  elevations  in  the  course  of  the  day  may  sometimes  persist 
throughout  the  entire  fastigium.  They  are  not  especially  rare  in  cases 
in  which  the  curve  in  general  exhibits  a  tendency  to  marked  remissions 
and  intermissions  (Fig.   15).     Concerning  the  causes  of  the  multiple 


Dav  of  the  disease. 


Fig.  11. — Temperature-curve  from  a  mild  case  of  typhoid  fever  of  regular  course  (after  Wunder- 

lich). 


Day 

-)f  th 

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isease 

T.  28  2E 

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Fig.  12.— Temperature-curve  from  a  case  of  typhoid  fever  in  a  previously  healthy,  robust 
man,  twenty-three  years  old.  Severe  case  of  typhoid  fever  of  regular  course.  Stage  of  con- 
valescence. 

elevations  of  temperature  nothing  is  known,  especially  with  regard  to 
those  that  persist  regularly  for  a  considerable  time.  As  a  transitory 
phenomenon  the  manifestation  is  not  at  all  rarely  caused  by  external 
disturbances,  in  part  by  mental  or  physical  exertion,  and  in  })art  also 
by  complications. 

The  stage  of  convalescence,  like  that  of  incubation,  has  by  no  means 
been  sufficiently  studied  with  relation  to  the  state  of  the  body-tempera- 
ture.    At  this  time  also  the  cur^^e  exhibits  a  typical  character  in  far 


SYMPTOMS  AND  COMPLICATIONS.  141 

greater  degree  than  in  the  case  of  the  other  acute  infectious  diseases. 
This  is  doubtless  due  to  the  more  protracted  duration  of  the  preceding 
febrile  stage,  which  naturally  must  exert  a  corresponding  influence 
upon  the  form  of  the  curve  in  the  afebrile  stage,  and  in  all  severe  and 
particularly  long-protracted  cases  may  cause  the  stage  of  convalescence 
to  be  characterized  by  emaciation. 

The  first  period  after  defervescence  may  be  most  appropriately 
designated  as  the  stage  of  subnormal  temperature.  In  detail,  the  curve 
pursues  such  a  course  that,  on  the  morning  following  the  last  febrile  day, 
less  commonly  on  the  next  succeeding  day,  the  body-temperature  declines 
to  36°  C.  or  lower. ^  From  this  time  on,  after  a  febrile  stage  of  rather 
severe  or  long-protracted  course,  it  remains  about  36°  C.  or  considerably 
below,  continuing  at  times  up  to  one  and  a  half  or  even  two  weeks,  and 
rarely  even  longer.  If  the  patient  is  kept  at  rest  physically  and  men- 
tally and  in  bed,  the  daily  fluctuations  at  this  time  generally  remain 
unusually  slight — slighter  than  the  physiologic.  They  are  then  scarcely 
more  than  half  a  degree,  generally  less,  so  that  in  the  evening  the  body- 
temperature  rises  little  above  36°,  at  most  to  36.5°  C.  With  the  progress 
of  convalescence,  the  daily  fluctuations  in  the  temperature  become  some- 
what greater,  approximating  the  physiologic,  and  then  the  temperature 
begins  to  rise  again,  until,  at  the  beginning  or  the  end  of  the  second 
week  of  the  afebrile  stage,  rarely  at  the  beginning  of  the  third  week, 
it  has  reached  the  level  normal  to  the  individual  (Fig.  12). 

Both  during  the  stage  of  subnormal  temperature,  as  well  as  during 
the  succeeding  period,  the  course  of  the  temperature  in  convalescents,  how- 
ever uniform  it  appears  to  be  during  rest,  may  exhibit  marked  instability. 
All  possible  external  and  internal  influences — slight  mental  excitement, 
visits,  news,  hopes  and  disappointments,  slight  dietetic  errors  or  transi- 
tory constipation — now  generally  give  rise  to  sudden,  often  not  incon- 
siderable, elevations  of  temperature.  Even  though  the  temperature  do 
not  rise  from  the  subnormal  much  above  the  normal,  the  elevation  is 
nevertheless  attended  with  symptoms  common  to  actual  febrile  states. 
Individuals  presenting  persistent  subnormal  temperature  for  a  consider- 
able time  exhibit  febrile  symptoms,  even  at  temperatures  that  during 
health  fall  within  the  limits  of  the  normal. 

The  stage  of  subnormal  temperature  in  severe  protracted  cases  ter- 
minating favorably  is  as  sharply  and  constantly  marked  as  aU  the  other 
stages  of  the  febrile  period.  When  it  does  not  immediately  follow  the 
stage  of  steep  curves,  the  possibility  of  irregularities  must  be  thought  of, 

1 1  have  observed  cases  in  which  the  temperature-curve  remained  subnormal  for 
as  Ions;  as  three  weeks  and  even  lonsrer  after  defervescence. 


142 


TYPHOID  FEVER. 


and  suspicion  should  especially  arise  that  the  morbid  process  has  not 
entirely  subsided.     As  a  rule,  recrudescences  or    relapses  then    occur. 

These  are,  furthermore,  to  be  ex- 
pected if  enlargement  of  the  spleen 
does  not  disappciir  with  reduction 
in  the  body-temperature.  It  will 
be  instructive  at  the  conclusion  of 
this  section  to  rej)r()duce  half-dia- 
grammatieally  the  entire  tem})era- 
ture-cur\e,  not  alone  that  of  the 
initial  and  the  febrile  stages,  but 
also  that  of  the  period  of  incuba- 
tion and  that  of  convalescence 
(Fig.   13). 

Duration  and  Form  of 
the  Individual  Sections  of 
the  Curve. — The  time  of  the 
first  ascent  of  the  temperature= 
curve  usually  occupies,  as  has 
been  previously  mentioned,  from 
three  to  five  days,  and  then  espe- 
cially, less  commonly  in  adults,  it 
may  take  longer.  There  also  oc- 
cur, however,  cases  in  which  the 
period  of  ascent  is  shorter;  thus 
the  temperature,  rising  by  steps, 
may  reach  its  height  in  forty-eight 
hours,  or  may  even  in  still  shorter 
time  rise  at  a  single  jump  to  the 
beginning  of  the  level  of  the  con- 
tinued fever.  In  the  latter  event 
the  febrile  period  often  sets  in  with 
a  chill,  which  is  a  rare  occurrence 
in  cases  attended  with  a  slow,  step- 
like ascent. 

The  old  rule  of  Wunderlich, 
that  in  a  case  of  typhoid  fever 
the  temperature  after  the  com- 
mencement of  the  ascent  does 
not  return  to  the  normal  even  during  the  morning  hours,  still  holds 
good  for    the    overwhelming  majority  of  all  cases.       But  rarely,  and 


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SYMPTOMS  AND  COMPLICATIONS.  143 

theu  mostly  in  mild  or  abortive  cases,  the  step-like  ascent  of  the  tem- 
perature is  modified  by  a  transitory  decline  to  the  normal  or  l^elow  in 
the  morning. 

Exceedingly  rapid  ascent  of  the  initial  temperature  is  encountered 
far  more  frequently  in  children  than  in  adults,  and  in  the  former  the 
fastigium  and  the  stage  of  defervescence  also  are  often  greatly  abridged. 
In  general — and  this  refers  to  children  and  adults  alike — a  rapid  ascent 
of  the  temperature  is  peculiar  rather  to  the  milder,  and  therefore  to  the 
shorter  or  even  abortive,  cases. 

Far  greater  variability  with  relation  to  the  duration  and  the  form  of 
the  curve  is  exhibited  by  the  period  of  febrile  elevation  than  by  the 
initial  stage.  If  the  curves  of  a  few  cases,  mild  and  severe,  are  placed 
side  by  side,  nothing  of  a  typical  character  would  be  noted.  If, 
however,  large  series  of  charts  are  studied,  some  regularity  will,  on 
the  whole,  be  observed.  Wunderlich  has  distinguished  two  large  groups 
of  cases  depending  upon  the  duration  of  the  height  of  the  disease. 
In  the  first  he  includes  short  cases  of  three  weeks'  duration  or  not 
much  longer,  with  a  fastigium  of  from  a  week  to  a  week  and  a  half; 
and  in  the  second  he  includes  protracted  cases,  in  which  the  fastigium 
lasts  from  three  to  six  weeks  and  even  longer.  Between  these  there  are 
naturally  all  possible  gradations  and  variations,  approximating  more  or 
less  to  one  or  the  other  variety.  Finally,  there  is  a  group  of  atypical 
cases  to  be  considered,  to  which  Wunderlich  attached  far  too  little 
importance,  in  which  the  temperature-curve  exhibits  absolutely  nothing 
characteristic.  The  first  of  Wunderlich' s  groups  includes  almost  solely 
mild  cases  that  regularly  terminate  in  recovery,  or  those  that  pursue  an 
unfavorable  course  only  in  consequence  of  accidental  unfavorable  con- 
ditions and  complications,  such  as  intestinal  hemorrhage,  perforation,  etc. 
The  second  group,  as  such,  has  little  relation  to  the  course  and  the  mode 
of  termination.  Although  this  group  includes  the  majority  of  the 
severest  cases,  it  comprises  also  many  of  moderate  severity,  even  down 
to  the  mildest. 

The  total  duration  of  the  febrile  stage,  concerning  which  a  few  statis- 
tical statements  may  be  made  before  we  pass  to  special  consideration  of 
variations  in  its  course,  is  considerably  longer  than  in  most  other  acute 
infectious  diseases.  For  adults  up  to  the  age  of  fifty-five  years  it  was  in 
more  than  half  of  my  cases  (50.5  per  cent.)  not  more  than  twenty-one  days. 
In  not  a  few  cases  it  was,  however,  from  twenty-two  to  thirty-three  days 
(29.3  per  cent.),  while  only  in  14  per  cent,  was  the  febrile  stage  longer  than 
this.  The  last  event  was  observed  especially  in  the  aged  and  in  pre%dously 
debilitated  persons.  The  course  of  the  fever  is  then  likely  to  be  oscillating 
and  irregular.  In  children  the  febrile  stage  is,  on  the  whole,  shorter. 
Among  443  children  up  to  the  age  of  fourteen  years,  in  whom  I  made 


144 


TYPHOID  FEVER. 


observations  upon  this  point,  I  found  a  duration  of  twenty-one  days  or  less 
in  6S.d  per  cent.  ;  of  between  twenty-two  and  thirty-three  days  in  16 
per  cent.  ;  of  more  than  thirty-three  days  in   7.5  per  cent. 

If  the  older  children  are  separated  from  the  younger,  it  will  be  seen 
distinctly  that  the  former  rather  a[)proximate  the  type  of  adults.  The 
duration  of  the  fever  was  : 


Twenty-one  days  or  less 

Between  twenty-two  and  thirty-three  days 
More  than  thirty-three  days 


In  children  between  '  t„  „v,;i/i-^.,  „.^  *«  <^u^ 
eleven  and  fourteen  ,  ^"  ^^'llT'  "P!°  ^'^® 
years  old  inclusive.  I      age  of  ten  years. 


60.0  per  cent. 

25.7  " 

11.8  " 


81.9  per  cent. 
11.3        " 
4.8        " 


Day  of  the  disease. 


With  regard  to  the  peculiarities  in  the  course  of  the  fever,  let  us  now 
consider  the  severe  and  the  severest  cases.  Both  those  of  short  duration 
and  those  of  more  protracted  course  in  adults  up  to  the  thirty-fifth  or 
the  fortieth  year  of  life  generally  exhibit  a  considerable  degree  of 
elevation  and  noteworthy  regularity  of  the  temperature.  The  differ- 
ence between  morning  and  evening  temperature  is  generally  not  more 
than  one  degree,  often  less  ;  while  the  average  morning  level  is  from  39° 
to  40°  C,  and  the  evening  level  up  to  40.5°  C.  and  above.  Of  itself  it  is 

of  grave  omen  if  with  a  high 
temperature  but  slight  morning 
remissions  take  place,  especially 
if  the  temperature  remains  un- 
influenced in  spite  of  the  em- 
ployment of  cold  baths  or  other 
antipyretic  treatment  (Fig.  14). 
If  the  temperature  be  especially 
high,  possible  complications 
should  be  carefully  looked  for. 
Septic  conditions,  pneumonia, 
and  secondary  meningitis  are 
especially  to  be  kept  in  mind. 

At  times  the  severe  contin- 
ued fever  is  interrupted  by  one 
or  more  marked  intermissions. 
The  temperature  then  declines  suddenly,  more  frequently  durmg  the  day 
than  during  the  night,  often  falling  several  degrees,  and  not  rarely 
fiillino-  far  below  the  normal.  Marked  simultaneous  diminution  in 
the  size  of  the  pulse,  with  considerable  increase  in  its  frequency, 
stamps  this  occurrence  as  true  collapse  (Fig.  23).  Less  commonly,  and 
then    especially  in    mdividuals    between   the  ages  of  twenty-five   and 


Fig.  14.— Temporatnre-curve  from  a  case  of  ty- 
phoid fever  in  a  man,  twenty-two  years  old.  Un- 
usually severe  course  without  special  complica- 
tions.   Death  on  the  fourteenth  day  of  the  disease. 


SYMPTOMS  AND  COMPLICATIONS. 


145 


thirty  years,  not  less  marked  variations  in  the  curves  occur  temporarily 
without  obvious  cause,  but  unattended  with  corresponding  diminution  in 
tension  and  size  of  the  pulse  and  without  increase  in  its  frequency. 
Such  interruptions  of  the  high  continued  fever,  in  other  respects  also 
not  attended  with 
alarming  symptoms, 
and  which  are  desig- 
nated pseudocollapse, 
I  have  observed  in 
several  cases  in  which 
there  were  two  or 
three  elevations  daily 
(Fig.   15). 

The  explanation  of 
this  remarkable,  and 
from  the  prognostic 
standpoint  generally 
indilFerent,  occurrence 
will  long  remain  ob- 
scure. 

In  the  presence  of 
such  pseudocollapse, 
however,  the  progno- 
sis should  be  guarded 
if  the  stage  of  steep 
curves  does  not  soon 
thereafter  begin  or  the 
intermissions  do  not 
actually  make  their 
appearance.  Should, 
on  the  contrary,  the 
body-temperature  rise 
again  to  its  previous 
level,  so  to  continue 
in  the  form  of  the 
earlier  continued  or 
remittent  continued  form,  the  further  course  of  the  case  mav  be  expected 
to  be  severe.  I  have  then  subsequently  observed  true  collapse,  during 
which  death  occurred.  If  severe  cases  of  long  duration  begin  to  pursue 
a  more  favorable  course,  the  high  continued  fever  is,  at  the  end  of  the 
second  or  the  commencement  of  the  third  week,  generally  converted  into 

10 


146 


TYPHOID  FEVER. 


a  remittent  or  even  an  intermittent  fever  witli  diiferenees  of  from  1.5° 
to  3°  C  and  more  between  morning  and  evening  temperatures  (Fig.  IG). 

The  eurve  may  then  continue  for  eight 
days  and  more,  either  with  regularly  re- 
peated remissions,  or — and  this  aj)plies 
especially  to  severe  cases — days  of  high 
continued  fever  alternating  with  others 
of  remittent  continued  fever.  Less  com- 
monly, in  my  experience,  beginning  im- 
provement is  characterized  by  the  circum- 
stance that  the  high  average  temperature 
gradually  subsides  without  increase  in 
the  remissions  or  with  only  isolated 
considerable  daily  fluctuations. 

The  less  common  cases  of  severe 
protracted  course  in  childhood  exhibit 
with  especial  frequency  a  form  of  tem- 
perature-curve with  marked  remissions 
and  intermissions.  E^'en  when  in  the 
severest  cases  the  fastigium  exhibited  at  the  beginning  the  characteris- 
tics of  a  continued  fever,  this  period  is  likely  to  be  much  shorter  and 
soon  to  be  replaced  by  a  period  of  marked  fluctuations.  These  mark- 
edly intermittent  curves  are  most  constant  in  children  up  to  the  eleventh 
year,  while  older  children  up  to  the  fourteenth  year  more  frequently 
exhibit  the  conditions  observed  in  adults. 


Diiy  of  the  disease. 

p. 

T.  16  17  18  19  20  21  22  23  2't  25 

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, -=x"  xltfcxf  r 

36          1       1       y     1  f   r 

W 

|!        '      ''■       |i# 

~~\                 c 

35_                 ^±               -, 

Fig.  16.— Temperature-chart  from 
a' case  c)f  typhoid  fever  of  moderate 
severity  in  a  man,  thirty-four  years 
old.  Marked  fluctuations  in  the  tem- 
perature-curve without  corresponding 
alterations  in  pulse  frequency. 


Day  of  the  disease. 


Fig.  17.— Tempernture  curve  from  iin  exceedingly  severe  protracted  case  of  typhoid  fever  in  a 
nuin,  fifty-;-ix  years  old.     'ihe  temperature-curve  exhibits  a  senile  form. 

The   form  of  the  temperature-curve  is  quite  remarkable  in  severe 
cases    in  persons    of  the    age  of   forty-five    years  and  above,  as  it  is 


SYMPTOMS  AND   COMPLICATIONS.  147 

often  also  in  younger  adults  who  liave  become  old  prematurely  or  debili- 
tated by  a  dissipated  mode  of  life,  alcoholism,  or  exhausting  chronic 
disease.  Under  such  circumstances  the  temperature,  in  spite  of  the 
most  severe  course  of  the  disease  and  the  most  alarming  general  condi- 
tion, remains  not  rarely,  even  at  the  height  of  the  attack,  remarkably  low, 
so  that  during  the  morning  hours  the  temperature  scarcely  rises  above 
the  normal  or  remains  below,  and  at  night  does  not  exceed  39°  C.  The 
form  of  the  curve  in  such  cases  is  remarkably  irregular  :  marked  remis- 
sions alternate  with  wide,  collapse-like  fluctuations,  and,  while  death  is 
likely  to  occur  almost  always  in  young  patients  while  having  exceed- 
ingly high  temperature,  under  the  circumstances  in  question  marked 
preagonal  decline  of  body-temperature  may  take  place.  Inexperienced 
observers  may  readily  be  deceived  by  the  low  temperature-level  during 
the  course  and  by  the  fall  at  the  most  serious  period,  and  thus  be 
tempted  to  give  a  favorable  prognosis  (Fig.  17). 

The  mild  and  the  mildest  cases  of  typhoid  fever  pursue  their  course 
at  times  speedily,  in  a  week  or  only  a  few  days,  and  accordingly  with  a 
scarcely  appreciable  fastigium ;  but,  on  the  other  hand,  they  may  be 
unduly  prolonged.  We  shall  later  return  to  the  separate  consideration 
of  abortive  and  the  mildest  afebrile  cases.  Here  only  the  mild  cases, 
lasting  up  to  three  weeks,  and  the  protracted  mild  cases,  will  be  dis- 
cussed fully.  The  mild  cases,  lasting  three  weeks,  most  frequently 
resemble  of  all  the  forms  the  typical.  With  a  relatively  short  duration 
the  individual  stages  are  characteristically  marked  in  the  curve  (Fig. 
11,  p.  126).  After  the  height  of  the  fever  has  been  reached  within 
two  and  half,  at  the  latest  four,  days,  the  duration  of  the  true  continued 
fever  is  likely  to  be  from  four  or  five  days  to  a  week.  Then  there  occur 
more  marked  fluctuations  of  temperature  of  1.5°  C,  and  frequently 
much  more,  at  first  still  with  rise  of  the  evening  temperature  to  that  of 
the  preceding  day,  after  which,  at  the  end  of  the  second  and  the  begin- 
ning of  the  third  week,  the  decline  begins  in  the  form  of  a  true  steep 
curve. 

Another  exceedingly  common  variety  of  mild  course  is  that  which 
from  the  beginning  exhibits  great  daily  fluctuations  in  the  temperature- 
curve,  with  complete  absence  of  true  continued  fever,  or  with  an  indi- 
cation of  this  for  two  or  three  days  at  most.  In  some  cases  the  inter- 
missions exhibit  such  regularity  and  uniformity  as  to  time  as  are 
observed  in  cases  of  true  intermittent  fever.  If,  under  such  circum- 
stances, the  remaining  symptoms  of  typhoid  fever  are  not  sufficiently 
well  marked,  difficulty  and  error  in  diagnosis  may  readily  arise  (Fig.  18). 

Especially  the  markedly  intermittent  and  remittent"  cases,  particularly 


148 


TYPHOID  FEVER. 


those  with  considerable  irregularity  in  the  form  of  the  curve  and,  on  the 
whole,  moderate  elevation  of  temperature,  are  at  times  of  unusually  long 
duration,  without  the  appearance  of  any  alarming  symptoms  throughout 
the  entire  course.  In  not  a  few  cases  with  an  intcTmittent  curve  the 
initial  stage  also  exhibits  this  character,  and  recrudescences  and  relapses 
are  also  likely  to  be  attended  with  equally  marked  fluctuations  in  the 
curve.  Alsb,  certain  cases  of  ambulatory  typhoid  fever  are,  in  my 
experience,  attended  with  considerable  remissions  in  the  temperature- 
curve,  at  times  even  with  such  marked  intermissions  that  in  the  morn- 
ing or  late  in  the  evening  or  during  the  night  the  temperature  is 
scarcely  above  the  normal  level,  while  considerable  elevations  take  place 
only  duruig  the  midday  or  for  a  short  time  late  in   the  aiternoon.     I 


Dav  of  the  disease. 


Fig.  18. — Temperatiire-chiirt  from  a  mild  case  of  typhoid  fever  in  a  girl,  eigliteen  years  old. 
From  the  twentieth  day  of  the  disease  the  course  of  the  attack  was  afebrile.  The  curve  was 
markedly  intermittent  from  as  early  as  the  sixth  day.  The  fever  was  almost  purely  of  quotidian 
type. 


have  in  a  number  of  instances  observed  that  in  such  cases  the  diagnosis 
of  malaria  was  made,  and  with  all  the  greater  certainty  when  the  eleva- 
tion of  temperature  was  initiated  with  a  chill.  Only  when  the  patients 
went  to  bed  and  roseolse,  splenic  enlargement,  and  characteristic  stools 
appeared  was  the  diagnosis  corrected. 

In  cases  of  mild  typhoid  fever  in  children  the  remittent  and  inter- 
mittent form  of  the  curv^e  is  usual.  Under  such  circumstances  the 
temperature-curve  is  very  rarely  regular,  like  that  of  intermittent  fever. 
On  the  contrary,  the  most  marked  irregularity  is  the  rule.  Unusually 
marked  fluctuations  in  the  curs^e,  alternating  with  periods  of  lower  level 
or  with  periods  of  causeless  low  temperature,  the  inverted  type  with  low 
evening  and  higher  morning  temperature,  often  combine  with  a  number 
of  other  irregularities  to  make  a  quite  remarkable  curve.     At  the  same 


SYMPTOMS  AND  COMPLICATIONS.  149 

time,  the  course  of  such  cases  is  often  protracted,  so  that  the  febrile 
period  may  continue  for  as  many  as  six  or  even  eight  weeks,  and  the 
patience  of  the  friends  and  the  physician  may  be  sorely  tried. 

Too  much  attention  cannot  be  paid  to  the  intermittent  and  remit- 
tent febrile  courses  described  and  to  the  great  irregularities  of  such 
curves.  One  who  is  unfamiliar  with  and  incapable  of  interpreting 
them  is  exposed  to  the  liability  of  great  error  in  diagnosis  and  prog- 
nosis. It  is  especially  in  such  cases  that  cryptogenetic  septicemia, 
miliary  tuberculosis,  and  other  diseases  far  more  feared  than  typhoid 
fever  are  often  incorrectly  diagnosed.  It  has  already  been  noted  that 
not  much  is  known  in  general  with  regard  to  the  causes  of  the  marked 
fluctuations  in  temperature.  The  conditions  are  different  with  regard 
to  influences  that  temporarily  exert  such  an  effect.  Especially  mtes- 
tinal  hemorrhage  and  extensive  peritonitis  are  to  be  mentioned  m  this 
connection.  Persistent  diarrhea  also  is  often  responsible  for  marked 
remissions  and  irregularities  in  the  curve.  Transient  marked  eleva- 
tions of  temperature  without  grave  significance  may  often  be  attributed 
to  extraneous  exciting  influences,  mental  as  well  as  physical.  The 
high  temperatures  observed  in  the  first  hours  after  entrance  of  the 
patient  into  the  hospital  are  familiar,  and  these  are  often  not  again 
attained  throughout  the  entire  attack.  They  are  undoubtedly  referable 
to  the  disturbances  associated  with  separation  from  one's  family  and  to 
the  transportation.  Not  less  familiar  are  the  febrile  elevations  in  cases 
of  typhoid  fever  after  the  presence  of  visitors,  as  well  as  those  that  are 
caused  by  protracted  conversation,  exciting  news,  dietetic  error,  or  get- 
ting out  of  bed  contrary  to  instructions.  Naturally,  all  of  these  occur- 
rences are  permissible  in  explanation  of  sudden  elevation  of  temperature 
only  when,  after  most  thorough  examination,  this  cannot  be  attributed 
to  some  local  complication  or  to  sudden  exacerbation  of  the  general 
process. 

Variations  in  the  Curve  in  the  Stag^e  of  Defervescence. — 
In  the  large  majority  of  all  cases  of  typhoid  fever,  the  severe  and  the 
moderately  severe,  as  well  also  the  milder,  if  they  have  m  the  preced- 
ing stages  approached  the  typical  form  of  the  curve,  the  transition  of  the 
temperature  to  normal  is  likely  to  take  place  in  the  form  of  the  so-called 
steep  curve.  This  period  lasts  for  from  three  to  eight  days  in  cases  of 
moderate  and  not  too  protracted  course.  Quite  generally,  after  severe  as 
well  as  after  mild  cases,  the  curve  passes  far  below  the  normal  with  the 
last  marked  decline,  so  that  on  the  morning  follow^ing  the  first  afebrile 
evening  the  temperature  will  be  between  35°  and  36°  C.  The  tem- 
perature then  varies  in  different  cases  :  it  may — as  is  not  uncommon 


150 


TYPHOID  FEVER. 


ami  has  boon  described — remain  subnormal  for  a  week  and  longer,  the 
stage  of  emaciation  thus  following  immediately.  In  other  cases,  after 
the  normal  has  been  reached,  there  follow  more  or  less  marked,  irre«>'nlar 
fluctuations  in  the  curve,  through  which  the  physiologic  evening  tem- 
perature is  reached  and  probably  also  is  exceeded.  After  this  has  con- 
tinued for  a  few  days  and  the  disease  tends  toward  definitive  termina- 
tion, the  characteristic  stage  of  emaciation  begins.  Only  in  the  mildest 
cases  can  recovery  and  return  of  the  temperature-curve  to  the  preceding 
physiologic  form  and  level  follow  immediately,  without  the  occurrence 
of  the  stage  of  emaciation. 

The  cases  are  not   rare  in  which  the  decline  of  temperature  takes 
place  not  with  great  fluctuations,  but  gradually.    This  uniform  decline  is 

Day  of  the  disease. 


T.  21  22  23  2it  25  26  27  28  29  30  31  32  33  3^4  35  36  37  38  39  W  41  kZ  43  -V«  'i5  A6  VI  ^8  'tO  50  51  52 

r              1                       r                                                 I 

'                                       i                       1 

/n      '                            -+-                                         It              ^                             1 

^X-.      ^i          r-  _  jt      (.  ,-     ,jn                  j:        ± 

JS   B   4    [        ^        C          J4      -i  -Ji        lA                            jZ  ■ 

g   \l.\A   i-lL          IlTi^ri^                     '           41 

^       jA  ft  ft       1         i\t-R                               itit 

39   _         it^jil^J   [   4-     fclj     --in       .    .±     -       -                t     __  _  - 

4    X-\         -.A                  jt                tt                                     1^1            jZ 

iT-   I       -    -   -    .      -t      vz.                               \ 

■3Q                  -        L^      in       _    _    _    _       r      TT          +                .1 

3^              llX^--  i  __l  -i      -     I    -j:               ^xji  .  i±    _ 

vtj      4  ±         I          t      x               53144      4               j 

^       I               I       31                        t           -                t         ti                                JL          5:4:                        I      i 

1-7                    I       tot        t     -       t       T              fl-        X-     -Ji    I 

3^                        [  tt  [      _.  _.   .-I:  .   J^         ^H  -    _£:.   .z  .   \ 

-^      ---          w        ^JSll          »    1   I    ,                   j 

--        -  -       4      pZ  ^  t         I      .   __  ^  (I  q 

oc                              it                                         114       li               1               '^          ^     ^        J     ) 

3^     -                       -  -            .I.E.                             _       *  e:     .,  Vr- 

itit                                      .     ^f    it                 .        ^                                                     T                pH 

.  ^L  4-             ai:                               _      ^  1 

OK                                     i  ^    X             ti                              It         1 

35       _      _       ±         __    it       -    I    -L_    _t^    -       H    -                   -           _      _      -U    _    _I^ 

it            it   '           J^            t           it                 it                 I 

it                                 IE       I     iti 

3^^-      !__+  ..ii_i:  I    iiiti  ^;ii-i    I  I  .:_i__i    i__--       -  "^i= 

Fig.  19. — Temperature-chart,  with  unusually  marked  fluctuations  in  the  temperature-curve 
before  the  primary  defervescence,  from  a  case  of  severe  typhoid  fever,  of  greatly  protracted 
course,  in  a  workman,  seventeen  years  old.  A  slight  recrudescence  began  on  the  forty-first  day 
of  the  disease. 

likely  to  be  completed,  on  the  average,  in  tAvo  or  three,  rarely  more,  days. 
Still  another  variety  of  defen^escence  is  that  in  which,  after  unusually 
marked  fluctuations  in  the  cui'\^e  persisting  for  days,  the  difference 
between  morning  and  evening  temperature  being  at  times  4  or  5 
degrees,  definite  reduction  in  temperature  takes  place  within  from 
twelve  to  eighteen  hours,  occasionally  within  a  still  shorter  time,  in  a 
single  stroke.  In  such  cases  I  have  obsers-ed  recrudescences  and 
relapses  Avith  remarkable  frequency  (Fig.  19).  At  times  this  variety 
of  sudden  decline  of  temperature  is  preceded  by  one  or  two  such  marked 
fluctuations,  after  the  curve  has  previously  preserved  the  characteristics 
of  a  remittent  continued  fever.  Under  such  circumstances  the  temper- 
ature-fluctuations are  more  often  initiated  and  accompanied  by  chills, 


SYMPTOMS  AND   COMFLrCATIONS. 


151 


and  this  may  at  times  cause  great  embarrassment  in  diagnosis.     This 
may  be  transformed  into  satisfaction  if  it  soon  appears  tliat  this  is  only 


Day  nf  the  disciiso. 

toll  21  22  23  2/i  25  2«)  27  28  29  30  31  32 

I 

1 

t    + 

W1       "                 fl     1 

^L.  __..__! 

'ft 

A 

A  » 

1Q       ^^         5 

r " 

"         1  " 

yo  _      _  I  .   +;      , 

:        I  —     It 

.    _        - 

fc        -J        A 

-^7   X                                J^'' 

•i' L.  ,--_-_U_L - 

f^ ^y-^--  — 

t     ^                              '^^^i. 

Ju                                 [ 

yiiiy  of  (hf  flis^a'-f 

T  19  20  21  22  23  24  25  26  27  28  20 

r       '            I    1 

it     i  ^IIT      1        .  T 

^1  -- JJ  + 1  -_t  -- 

III' 

/lO  -.5"'"  _!fcl:  "" "  "±i    X. 

j:i^\TuX     ^iTi-^ 

,  ^  T  "^  X  V  It       It  H  It   L 

o,^it4IJ  Jt^^SI       Z-itit-d 

39*     lU'T     vtl       ^^^X 

~     1    T-X"     JtltXT        -L 

*      it     intit 

38^                                       +       ~t 

1 

itit 

37                    in  ''  it  it 

_ A  .--j---*--i- 

i,ZJ1j_aX. 

IT          :jC±5i3^± 

3fi XtLZ-luU. 

i: — in — iitrf: 

in         it± 

1            1    1 

^      .-             ±:±±xx 

Fig.  20. — Temperature-chart  from  a  severe 
case  of  typhoid  fever  in  a  woman,  tliirty-six 
years  old.  Defervescence  with  two  marked 
fluctuations  in  the  curve,  with  chills. 


Fig.  21.— Temperature-chart  from  a  severe 
case  of  typhoid  fever  in  a  woman,  thirty-one 
years  old.  From  the  twenty-fourth  to  the 
twenty-fifth  day  of  the  disease  there  occurred 
a  critical-decline,  without  antecedent  marked 
fluctuation  in  the  curve. 


Day  of  the  disease. 


a  peculiar  form  of  reduction  in  the  curve,  and  not  an  indication  of  a 
complication  (Fig.  20). 

It  is  probably  least  frequent  for  the  remittent  continued  fever  of  the 
fastigium  to  terminate  suddenly,  with  a 
critical  decline,  at  a  single  stroke,  or 
for  the  crises  to  be  preceded  only  by  a 
precritical  elevation  on  the  preceding 
evening.  I  have  observed  this  variety 
of  defervescence  more  frequently  in 
young  persons,  and  especially  in  chil- 
dren, but  it  occurs  also  now  and  then 
in  adults  (Figs.   21   and  22). 

Finally,  in  the  less  common  cases  of 
typhoid  fever  that  pursue  an  irregular 
and  protracted  course  or  are  attended 
with  relatively  low  temperature  in  the 
presence  of  severe  general  manifesta- 
tions, often  no  marked  transitional 
stage  in  the  curve  can  be  noted.  This 
stage  then  pursues  an  irregular  course,  with  more  or  less  marked 
fluctuations,  the   morning  and   evening  temperatures    becoming  grad- 


FiG.  22. — Tt-mperature-chart  from  a 
mild  attack  of  typhoid  fever  in  a  man, 
tweiity-flve  years  old.  Critical  decline 
of  the  temperature  with  defervescence 
after  precritical  elevation. 


152  TYPHOID  FEVER. 

ually  lower,  and  the  normal  temperature  is  slowly  reached.  Viewed 
anat(^mically,  these  are  perhaps  cases  with  slowly  healing-  ulcers,  with 
rccnuU'seciKvs  and  sluggish  lesions.  These  are  the  cases  also  in  which 
for  a  long  tinic  doubt  exists,  and  certainty  may  be  wanting  at  times  even 
after  the  end  of  the  disease,  as  to  what  parts  of  the  curve  belong  to  the 
actual  typhoid  process  and  what  to  possible  complications  and  sequels. 
The  alterations  in  the  form  of  the  curve  in  connection  with  definite 
modes  of  course  of  the  typhoid  attack,  and  with  important  sequels 
and  complications,  will  be  more  appropriately  discussed  in  the  respec- 
tive chapters. 

CHANGES  IN  THE  CIRCULATORY  ORGANS. 

The  discussion  of  these  will  be  taken  up  here  on  account  of  the 
intimate  relation  of  the  heart  and  the  pulse  to  the  fever,  and  especially 
to  the  state  of  the  body-temperature.  It  is  well,  for  reasons  that  will 
later  be  UKjre  fully  detailed,  to  separate  in  the  description  cases  without 
especial  cardiac  disorders  and  those  with  severe  heart-aflPections. 

We  shall  begin  with  a  consideration  of  the  character  of  the  pulse 
in  cases  pursuing  an  uncomplicated  course.  In  all  stages  of  such  cases 
a  close  correspondence  exists  between  the  form  of  the  pulse-curve  and 
the  state  of  the  temperature. 

In  the  initial  stage  it  will  be  observed  in  the  majority  of  cases  that 
the  increase  in  the  frequency  of  the  pulse  takes  place  in  the  same  step- 
like manner  as  the  ascent  of  the  temperature-curve.  In  some  cases  the 
form  of  the  pulse-curve  imitates  exactly  that  of  the  temperature-curve. 
In  other  instances  the  pulse-frequency  rises  relatively  more  slowly  ; 
Avhile  in  irritable  individuals,  on  the  contrary,  it  reaches  its  highest 
average  level  more  quickly  than  the  temperature-curve,  persisting  also 
during  the  first  period  of  the  continued  fever.  Likewise,  during  the 
period  of  fever-height,  both  curves  often  exhibit  a  striking  parallelism. 
In  the  amphibolic  stage  the  pulse-frequency  then  generally  declines, 
still  more  so  in  the  period  of  steep  curves,  so  that,  if  the  temperature 
has  again  reached  the  normal  or  has  fallen  below  this,  the  pulse- 
frequency  will  be  again  approximately  normal,  at  times  somewhat 
below,  at  other  times  above. 

In  general  it  may  be  stated  that  in  the  first  days  of  the  afebrile 
period  the  number  of  pulse-beats  more  frequently  is  relatively  high 
than  low,  the  former  especially  if  the  body-temperature  at  this  period 
does  not  become  subnormal,  but  remains  steadily  at  about  37°  C  or  above. 
This  parallelism  between  the  pulse-curve  and  the  temperature  is,  accord- 
ing to  the  present  state  of  knowledge,  not  referable  to  the  action  of  the 


SYMPTOMS  AND   COMPLICATIONS.  153 

latter  upon  the  heart  and  the  cardiovascular  system,  as  earlier  writcir.s 
believed.  Both  are  due  rather  to  a  common  caus(!,  namely,  tlie  action 
of  toxins,  which,  in  accordance  with  the  intensity  of  the  infection  and 
the  reactive  susceptibility  of  the  individual,  reaches  a  definite  expression 
in  each  individual  case. 

Quite  remarkable  and  not  emphasized  in  deserved  degree  by  even  some 
recent  writers  is  the  relative  degree  of  infrequency  of  the  pulse  often 
observable  during  the  ascent  of  the  temperature-curve  and  througli- 
out  the  entire  stage  of  continued  fever.  In  other  words,  the  pulse 
in  many,  even  moderately  severe  and  severe,  cases  does  not  attain 
the  frequency  that  we  are  accustomed  to  encounter  in  other  infec- 
tious diseases  with  like  elevation  of  temperature.  This  is  observed 
especially  in  young,  robust  individuals,  up  to  about  the  fortieth 
year  of  life,  and  more  frequently  in  men  than  in  women.  It  is 
quite  generally  found  under  such  circumstances  that,  with  an  average 
temperature  of  39°  or  40°  C,  and  even  more,  the  pulse  ranges  about  80 
in  the  morning  and  between  90  and  100  in  the  evening,  rarely  rising 
higher.  Even  in  the  presence  of  severe  manifestations — marked  diar- 
rhea, meteorism,  and  slight  stupor — this  character  of  the  pulse  need  not 
be  absent.  As  a  matter  of  fact,  well-marked  cases  of  moderate  severity 
are  not  rarely  encountered  in  which  the  pulse-frequency  in  the  morning 
scarcely  exceeds  the  normal,  and  throughout  the  entire  course  of  the 
disease  does  not  reach  100  in  the  evening.  This  peculiar  relation 
between  pulse  and  temperature  is  responsible  for  the  familiar  character- 
istic appearance  of  the  charts  upon  which  both  are  recorded  simulta- 
neously with  the  remarkably  wide  separation  of  the  two  curve-lines. 
Of  all  febrile  diseases,  this  relation  occurs  by  far  most  frequently  in 
cases  of  typhoid  fever,  and  it  may  therefore  be  of  itself  an  excellent 
diagnostic  aid. 

As  has  appeared  in  several  connections,  the  course  of  the  disease  in  older 
children  approximates  that  in  adults  ;  so  also  the  relative  infrequency  of 
pulse  occurs  not  rarely  in  older  children,  although '  this  is  almost  always 
wanting  in  younger  children.  I  can  wholly  confirm  this  observation,  first 
made  by  Roger.'  While,  however,  the  statements  of  this  writer  apply  to 
children  after  the  sixth  year,  I  have  observed  the  phenomenon  almost  only 
in  those  between  the  tenth  and  the  fourteenth  year.  In  yonnger  children, 
on  the  contrary,  I  have  observed,  almost  without  exception,  rather  high 
pulse-frequency. 

For  adults  Liebermeister,''*  among  recent  writers,  emphasizes  the  infre- 
quency of  the  pulse,  and  he  mentions  Sauvages,  Hufeland,  and  Berndt  as 
earlier  witnesses  of  the  manifestation.  The  explanation  suggested  by 
Liebermeister,  that  the  typhoid  poison  induces  directly,  through  an  irritative 

^  Rech.  din.  sur  les  mal.  de  lH?ifance,  T.  i.,  Paris,  1872.  ^  Loc.  eit.,  p.  91. 


154  TYPHOID  FEVER. 

etiect  upon  the  central  nervous  syj?teni,  especially  the  medulla  oblongata, 
(liiuinutit)n  in  pulse-frecpiency,  appeal's  to  me  noteworthy  and  probable. 
Other  poisonous  substances,  as  the  biliary  acids  which  cinulate  in  the  blood, 
at  times  are  known  to  have  the  same  etiect.  Naturally,  the  interesting 
question  is  by  no  means  wholly  disposed  of  by  the  hypothesis  mentioned. 
Further,  possibly  experimental,  observations  are  urgently  necessary. 

It  is  noteworthy  that  among  the  well-known  earlier  observers  of  typhoid 
fever,  Griessinger,  Louis,  and  Murchison  considered  infrequeucy  of  the  pulse 
only  as  an  exceptional  condition. 

^^'ith  regard  to  the  quality  of  the  pulse  in  previously  healthy, 
robust  individuals  iu  the  initial  stage  and  at  the  height  of  the  dis- 
ease, it  ap})eurs  full  and,  particularly  iu  the  first  period,  notably  tense. 
If  special  circumstances  do  not  arise  during  the  course  of  the  disease, 
the  pulse  is  likely  to  remain  equal  and  regular  until  the  end  of  the 
febrile  period.  At  the  end  of  the  second  and  in  the  third  week,  in 
severe  cases  earlier,  the  pulse  quite  generally  is  noted  to  become  softer 
without  corresponding  diminution  in  its  fulness.  The  cause  of  this  mani- 
festation— the  reduction  in  the  tension  of  the  arterial  wall — is  respon- 
sible for  another  quite  usual  simultaneous  change  in  the  pulse  :  the  pulse 
becomes  dicrotic,  even  tricrotic,  and  in  extremely  rare  cases  polycrotic. 
Also,  this  character  of  the  pulse  again  is  undoubtedly  much  more 
frequent  m  cases  of  typhoid  fever  than  in  those  of  most  other  febrile 
diseases,  so  that,  ^vith  many  other  writers,  I  attach  diagnostic  signifi- 
cance to  it.  If  it  is  additionally  associated  with  the  relative  infrequency 
of  the  pulse  already  mentioned,  the  probability  of  the  existence  of 
typhoid  fever  is  thereby  increased. 

The  dicrotic  pulse  is  observed  most  frequently  and  most  distinctly 
in  adults,  even  in  elderly  persons,  unless  the  existence  of  atheroma 
prevents  the  conditions  necessary  for  its  occurrence.  In  children  the 
dicrotic  pulse  is,  in  my  experience,  observed  less  commonly  and  least 
commonly  in  young  children,  obviously  on  account  of  the  natural 
smallness  of  the  pulse,  due  to  the  physiologic  narrowness  of  the  arterial 
lumen.  In  older  children,  near  the  age  of  puberty,  I  have  observed 
dicrotisra  now  and  again.  In  very  severe,  and  especially  in  fatal,  cases 
the  dicrotism  generally  diminishes  and  soon  disappears,  entirely  at  the 
height  of  the  fever,  owing  to  the  diminution  in  the  fulness  of  the 
arterial  tube  and  in  pulse-tension.  Toward  the  end  of  the  febrile  stage 
iu  almost  all  severe  and  moderately  severe  cases,  and  also  in  mild  cases 
that  pursue  a  protracted  course,  the  pulse  becomes  smaller,  while  i^s 
softness  persists,  and  the  dicrotism  disappears. 

The  time  of  the  day  causes  no  material  difference  with  relation  to  the 
fulness  and  the  tension  of  the  pulse,  but  all  the  greater  difference  Avith 
regard  to  the  frequency.     It  may  be  stated  in  general  that  the  daily 


SYMPTOMS  AND   COMPLICATIONS.  -      155 

variations  of  the  pulse  in  cases  of  typhoid  fever  are  comparatively 
marked.  The  differences  in  pulse-frequency  at  the  hours  when  the 
temperature  is  highest  and  at  those  when  the  temperature  is  lowest  is 
likely  to  be  from  10  to  20  and  even  30  beats.  In  general,  the  high  and 
the  low  number  of  pulse-beats  and  the  high  and  low  degrees  of  tem- 
perature of  the  daily  curve  correspond  in  time.  If,  however,  more 
frequent  pulse-observations  are  made,  quite  marked  differences  can  be 
made  out,  especially  on  different  days  and  at  different  times  of  the  day. 
Undoubtedly,  the  variations  in  pulse-frequency  are  slightest  in  those 
patients  who  are  kept  especially  quiet  and  undisturbed  mentally  or 
physically.  In  this  respect — that  is,  in  so  far  as  they  take  little  notice 
of  what  goes  on  about  them — soporose  patients  resemble  them.  These 
patients  also  exhibit  comparatively  slight  daily  variations,  even  when 
the  frequency  is  considerable  and  the  tension  of  the  pulse  is  increased. 
All  of  these  facts  indicate  that  external  conditions  exert  an  important 
influence  upon  the  pulse-frequency.  In  entire  accord  with  this  state- 
ment is  the  fact  that  in  conscious  patients,  at  all  stages  of  the  disease,. 
excitement  of  the  most  varied  kind  makes  its  influence  apparent  in  the 
pulse-curve.  Every  hospital  physician  is  familiar  with  the  increased 
frequency  of  the  pulse  on  visiting  days.  Not  I'arely  the  physician,  with 
his  finger  on  the  pulse,  is  able  to  anticipate  the  wish  that  the  patient  is 
about  to  express,  since  the  frequency  of  the  pulse  then  suddenly  becomes 
increased.  This  tendency  to  transitory  increase  of  the  pulse  should 
always  be  borne  in  mind,  especially  from  the  prognostic  standpoint : 
it  is  one  of  the  peculiarities  of  the  typhoid  curve,  and  in  the  absence 
of  complications  is  almost  never  of  serious  significance. 

The  cases  are  to  be  interpreted  quite  differently  and  more  seriously 
in  which,  from  the  outset,  the  pulse-frequency  constantly  is  especially 
high  or  in  which  the  pulse-curve  reaches  a  rather  high  level  even  at  the 
commencement  of  the  period  of  febrile  elevation.  Under  such  circum- 
stances the  disease  may  be  expected  to  pursue  a  severe  course.  Apart 
from  this  fact,  persistent  acceleration  of  pulse-frequency  is  often  indi- 
cative of  complications  of  most  diverse  kind.  In  this  connection 
attention  should  be  directed  especially  to  inflammatory  affections  of  the 
lungs  and  the  heart,  not  less  than  to  the  possibility  of  complicating 
peritonitis  and  intestinal  hemorrhage.  With  reference  to  the  latter  two 
conditions,  the  pulse  is  all  the  more  noteworthy,  since  Avith  the  onset 
of  peritonitis  the  temperature  exhibits  a  most  inconstant  character, 
particularly  often  showing  no  elevation  whatever,  and  also  that  con- 
siderable intestinal  hemorrhage  may  exhibit  its  influence  upon  the  pulse 
before  the  discharge  has  taken  place   externally.     With  reference  to 


156 


TYPHOID  FEVER. 


intestinal  hemorrhagos,  it  is  ospecially  to  be  borne  iii  mind  further 
that,  if  at  all  considerable,  they  give  rise  to  rapid  fall  of  the  tem- 
perature. This  fall  of  temperature  and  the  increase  in  ])ulse-frequency 
give  rise  to  those  intersections  in  the  curve  (Fig.  24,  p.  222,  Digestion) 
familiar  to  the  experienced  clinician  as  most  ominous.  That  an  entirely 
similar  relation  between  pulse  and  temperature  may  also  attend  states  of 
collapse  of  other  origin  need  only  be  mentioned  at  this  i)la{'e  (Fig.  23). 
In  especially  severe  cases,  ])articularly  those  in  which  death  results 
from  the  intensity  of  the  infection,  the  pulse-curve  loses  all  its  charac- 
teristic features  in  the  last  days,  and  even  for  a  longer  time  previous  to 
death  :  fulness  and  tension  diminish  appreciably  after  the  dicrotism  has 
already  disappeared;    the   frequency  becomes    constantly-  higher,  with 


Day  of  the  d 

sease. 

T 

T.       9          lO        11          12         I 

3         l^f          15         16         17 

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Fig.  23. — Temperature-chart  from  a  severe  case  of  typhoid  fever  in  a  man,  twenty 
old,  with  collapse  without  directly  demonstrable  cause. 


seven  years 


progressively  diminishing  daily  fluctuations ;  finally,  the  pulse  is 
wholly  irregular,  scarcely  palpable,  and  not  to  be  counted  (Fig.  14). 
The  stage  of  defervescence  and  of  afebrile  convalescence  is  likewise 
deserving  of  especial  consideration  with  reference  to  the  })ulse,  such 
as  has  been  given  with  reference  to  the  course  of  the  temperature. 
Already  in  the  stage  of  steep  curves  the  pulse  frequently  becomes 
smaller  and  harder,  with  indistinctness  or  disappearance  of  the  dicro- 
tism. With  the  marked  fluctuations  in  temperature,  there  occur  not 
rarely  in  irritable  individuals  correspondingly  wide  fluctuations  in  the 
pulse-curve.  ]\Iore  frequently,  however,  the  latter  do  not  exhibit  a 
corresponding  extent  of  range,  but  they  may  be  conspicuously  smaller 
than  the  temperature-fluctuations,  so  that  no  more  than  the  physiologic 
daily  variations  appear. 


SYMPTOMS  AND  COMPLICATIONS.  157 

While  thus,  at  the  period  of  steep  curves,  in  patients  kept  perfectly 
at  rest  in  bed,  the  pulse  by  no  means  so  constantly  as  the  tem])erature 
exhibits  the  remittent  and  intermitted  type,  it  is  characterized  by 
unusual  and  far  more  marked  variability  with  every  deviation  of  tlie 
patient  from  the  typical  course  than  in  the  earlitir  stages.  Esj)ecially 
in  greatly  reduced  patients,  in  irritable  men,  in  women  and  children, 
extrinsic  and  intrinsic  influences,  themselves  inconsiderable,  induce  quite 
remarkable  variations  in  the  pulse-curve.  If  the  patient  sits  up  or 
turns  over  in  bed,  or  with  the  approach  of  the  physician  or  of  strangers, 
accelerations  up  to  from  100  to  120  or  130  are  quite  frequent. 

In  the  first  stage  of  convalescence,  which  we  have  designated  tliat 
of  subnormal  temperature,  the  pulse  in  the  majority  of  cases  does  not 
become  subnormal.  It  may,  moreover,  be  accepted  as  a  rule  that  it 
now  ranges  somewhat  above  the  physiologic  (individual)  normal,  at  about 
80  in  the  morning  up  to  100  in  the  evening.  The  transitory  wide 
fluctuations  due  to  mental  and  physical  disturbances  are  also  now  just 
as  common  as  in  the  stage  of  steep  curves. 

The  cases  are  infrequent  and  unexplained  in  which  in  the  stage 
of  subnormal  temperature  the  pulse-frequency  also  is  subnormal.  I 
have  observed  the  pulse  to  decline  to  50,  even  to  40,  in  the  evening, 
and  to  36  and  even  28  in  the  morning.  Under  such  circumstances 
it  is  always  conspicuously  small  and  slow,  and  at  the  same  time 
exhibits  all  of  the  characteristics  peculiar  to  states  of  emaciation. 
Possibly  in  most  cases  the  explanation  is  to  be  looked  for  in  this 
direction.  The  subnormal  pulse-rate  may  be  observed  to  persist 
at  times  for  only  a  few  days,  at  other  times  for  a  week  and  longer, 
or  into  the  period  in  which  the  temperature-curve  rises  to  the  physi- 
ologic level.  I  have  observed  this  infrequency  of  the  pulse  also  in 
association  with  the  clinical  manifestations  of  infectious  myocar- 
ditis, without  the  discovery  m  the  cases  in  question  of  any  explana- 
tory peculiarity.  Also,  during  the  second  period  of  convalescence,  in 
which  the  abnormally  low  temperature  again  rises  to  the  individual  level, 
the  pulse-frequency  is  likely  on  the  average  to  remain  relatively  high, 
although  always  with  a  special  tendency  to  transitory  marked  fluctua- 
tions. This  at  times  becomes  especially  alarming  to  young  physicians 
and  the  friends  when  the  patients  begin  to  be  more  lively  in  bed,  or 
after  eating,  or  straining  at  stool.  Even  for  the  first  few  davs  after 
getting  out  of  bed  considerable  acceleration  and  instability  of  the  pulse 
are  quite  usual.  In  some  patients  fourteen  days  elapse  before  the 
previous  frequency  and  uniformity  are  again  attained.  In  long- 
protracted,  especially  severe  cases  this  period  may  be  more  extended. 


158  TYPHOID  FEVER. 

It  need  scarcely  be  mentioued  specially  that,  on  the  whole,  previously 
normal  ])iilse-couditions  are  restored  far  more  rapidly  iu  healthy  young 
men  than  in  irritable,  previously  sick  individuals  or  women  and 
childrou. 

The  characteristics  of  the  pulse  described  occur  uuich  more  fre- 
quently during  convalescence  from  typhoid  fever  than  during  that  from 
other  acute  infectious  diseases,  especially  small-pox,  which  is  often  cited, 
typhus  fever,  and  relapsing  fever,  as  well  as  pneumonia.  It  will  thus 
be  seen  that,  like  the  state  of  the  body-temperature,  that  of  the  pulse 
is  also  of  important  diagnostic  and  prognostic  significance. 

From  the  diagnostic  point  of  view,  the  relative  infrequency  of  the 
])ulse  in  the  febrile  stage  and  the  dicrotism,  so  frequent  in  no  other 
infectious  disease,  may  finally  again  be  emphasized.  In  addition,  the 
diagnostic  significance  of  the  sudden  acceleration  of  pulse-frequency 
attending  conditions  of  collapse  and  varied  complications  may  be 
recalled.  From  a  prognostic  point  of  view  it  may  be  said  that  relative 
infrequency  of  the  pulse,  with  good  volume  and  tension  at  the  height  of 
the  disease,  is  of  good  significance,  while  dicrotism  and  poly  erotism  are 
without  special  significance  in  prognosis.  It  becomes  a  matter  for  con- 
cern if  tension  and  volume  of  the  pulse  fail  early.  Also,  marked  pulse- 
frequency  at  an  early  period  in  the  disease,  in  the  initial  stage,  or  at  the 
beginning  of  the  fastigium,  indicates,  if  at  all  persistent,  a  severe  course. 
This  is  especially  true  in  the  case  of  men  and  elderly  individuals,  while 
women  and  children  in  general  may  exhibit  considerable  acceleration  of 
pidse  without  serious  significance.  Frequently  repeated  acceleration 
of  the  pulse  to  130  or  140,  apart  from  children,  is  ominous  under  any 
circumstances.  Isolated,  quickly  subsiding,  marked  and  extreme  fluct- 
uations do  not  indicate  much,  at  least  in  the  terminal  stage  or  during 
convalescence.  Rapid  elevation  of  temperature  and  acceleration  of  pulse 
occurring  simultaneously  and  not  quickly  disappearing  are  of  grave 
significance.  Intersection  of  the  two  curs^es  in  such  a  manner  that  the 
pujse  is  greatly  accelerated  while  the  temperature .  declines  rapidly  is 
even  more  serious. 

Irregularity  and  inequality  of  the  pulse  must  be  considered  as  grave 
signs  at  all  stages,  but  most  so  naturally  in  the  earlier.  They  are  indica- 
tive of  cardiac  weakness  and  other  profound  functional  and  anatomic 
disorders  of  the  circulatory  organs.  Of  the  two,  the  inequality  is  of 
the  far  greater  significance.  Irregularity,  especially  transitory  inter- 
mission, may  occur  in  the  febrile  stage  as  well  as  during  convalescence 
— more  frequently  in  women  and  children  than  in  men — without  further 
consequences.      I  have  observed  such  intermission  of  the  pulse,  together 


SYMPTOMS  AND  COMPLTCATTONS.  159 

with  retardation  and  abnormal  slowness,  espeeially  in  the  stage  of  siil)- 
normal  temperature. 

Changes  in  the  Heart-muscle. — It  is  a  matter  of  ccnirse  that 
the  state  of  the  pulse  in  no  small  degree  reflects  tlie  condition  and  the 
functional  activity  of  the  heart — the  part  taken  })y  tJic  remainder  of  tlie 
circulatory  apparatus  is  not  yet  .sufficiently  known — and  it  would  there- 
fore be  advisable  to  discuss  both  together.  Separate  consideration  has 
already  been  given  the  pul^e  only  for  extraneous  reasons.  In  the  first 
place,  its  character  is  so  closely  related  to  that  of  the  temperature-curve 
that  for  this  reason  alone  a  certain  community  in  the  description  of  Ijoth 
seemed  necessary ;  and,  in  the  next  place,  in  spite  of  marked  recent 
advances  in  anatomic  knowledge  of  the  profound  changes  in  the  heart 
in  connection  with  typhoid  fever,  so  little  is  known  concerning  the 
anatomic  conditions  of  the  organ  in  mild,  moderately  severe,  and  even 
severe  "  uncomplicated  "  cases  that,  when  the  disease  pursues  its  ordi- 
nary course,  any  comprehension  of  the  relations  between  the  heart  and 
the  pulse  and  the  arterial  system  is  entirely  wanting. 

With  regard  to  the  condition  of  the  heart  in  the  initial  stage  of 
typhoid  fever  and  throughout  the  entire  course  of  mild  and  moderately 
severe  cases,  a  sufficient  number  of  thorough  anatomic  studies,  particu- 
larly such  as  will  meet  the  requirements  of  modern  methods,  have  not 
as  yet  been  made,  on  account  of  the  relative  rarity  of  death  at  this 
period.  From  the  clinical  and  the  physical  diagnostic  point  of  view 
nothing  especial  is  appreciable  in  the  heart  in  such  cases,  and,  as  will 
be  shown  directly,  nothing  is  made  out  also  in  many  cases  pursuing  a 
severe  uncomplicated  course.  That,  nevertheless,  simple  "  functional " 
disorders  of  the  heart  and  the  vasomotor  system  are  not  responsible  for 
such  characteristic  changes  in  the  pulse,  but  that  under  these  conditions 
at  least  slight  transitory  tissue-changes  take  place,  cannot  be  doubted. 
Of  severe  and  fatal  cases  of  typhoid  fever,  however,  it  has  long  been 
known  that  they  exhibit  profound  anatomic  lesions  corresponding  with 
the  clinical  manifestations.  For  the  present,  however,  they  cannot  be 
included  in  the  description  of  the  ordinary  anatomic  and  clinical  con- 
dition of  the  heart,  and  are  considered  as  severe  specific  localizations 
or  complications.  Perhaps  their  relations  are  comparable  to  those  of 
febrile  albuminuria  to  true  typhoid  nephritis. 

Laennec  early  mentioned  that    "heart-softening"    occurs  in  severe 

febrile,  especially  typhoid,  states.     Louis   and   Stokes   also   recognized 

anatomically  and  clinically  the  occurrence  of  profound  changes  in  the 

heart  in   cases   of  typhoid   fever.     Friedreich^   was    the   first   to   call 

^  Verhandl.  d.  phyaik.-med.  Gesellsch.,  "Wiirzburg,  1855. 


160  TYPHOID  FEVER. 

atteutiou  to  the  occurrence  of  acute  dilatation  of  the  heart  in  connection 
with  fever,  and  his  observations  were  verified  by  many  observers,  and 
were  incorporated  into  the  text-books  in  relation  also  to  typhoid  fever. 
It  is  known  at  the  present  day  (see  also  Anatomy)  that  the  profound 
typhoid  disorders  of  the  heiirt  are  dependent  u])on  parenchymatous 
degeneration  of  the  myocardium  as  well  as  upon  true  myocarditis. 
The  significance  of  these  changes  in  detail  has  not  as  yiet  been  fully 
cleared  up.  E.  Romberg,'  in  his  admirable  work,  has  properly  called 
attention  to  the  fact  that  the  various  parenchymatous  alterations  in  the 
niyocardiuin,  the  frequent  albuminous  degeneration  of  Virchow,  the  less 
connnon  waxy  degeneration,  the  segmentation  of  the  fibers,  the  diverse 
nuclear  changes,  and  the  fatty  degeneration  of  the  myocardium  can  be 
recognized  with  difficulty  from  their  clinical  manifestations.  Probably 
the  last  two  conditions  are  more  frequently  responsible  than  the  others 
for  morbid  manifestations  observed  during  life.  The  overwhelmingly 
preponderant  role  is  played  undoubtedly  by  the  interstitial  inflammatory 
processes  first  described  by  Hayem  f  a  limited  role  possibly  also  by  his 
specific  obliterating  endarteritis  '^  of  the  smallest  arterial  branches  of  the 
myocardium  and  the  pericardium. 

Clinical  Symptoms  of  Typhoid  Myocarditis. — Cardiac 
svmptoms  of  considerable  degree,  resulting  from  inflammatory  processes 
in  the  myocardium,  are  likely  to  begin  at  the  end  of  the  second  or  the 
beannninsr  of  the  third  week,  and  to  last  into  the  fourth  week  or  even 
longer.  As  Stokes  early  emphasized,  the  condition  is  principally  one 
of  cardiac  weakness  of  rapid  onset,  often  of  considerable  degree,  which 
does  not  always  accord  with  the  severity  of  the  general  course  and  the 
manifestations  on  the  part  of  other  organs.  The  pulse  especially 
becomes  unusually  frequent,  without  corresponding  rise  in  temperature, 
and  this  is  particularly  striking  in  young,  robust  individuals  who  pre- 
viously had  had  moderate  pulse-frequency.  Still  more  significant  are 
the  irregularity  and  inequality  of  the  pulse,  which  often  soon  appear, 
and  to  which  first  Griessinger  and  subsequently  Hayem  especially  called 
attention  in  this  connection.  Occurring  at  the  height  of  the  febrile 
period,  if  the  heart  was  healthy  before  the  onset  of  the  typhoid  disease, 
they  constitute  almost  certain  signs  of  important  changes  in  the  circula- 
tory apparatus.     To  the  acceleration  and  irregularity  of  the  pulse  there 

1  Arhrii.  a.  d.  med.  Klin.  z.  Leipsic,  Vogel,  Leipsic,  1893. 

*  Arch,  dephys.  mirm.  et  path.,  T.  ii.,  1869;  T.  iii.,  1870. 

=*  This  has  been  described  also  by  later  French  observers— H.  Martin  {Rev.  de  Med.., 
1881  and  1882),  Landouzy  and  Siredey  [Ibid.,  1885  and  1887),  while  Eomberg  was 
scarcely  able  to  demonstrate  it  in  spite  of  most  careful  investigation. 


SYMPTOMS  AND  COMPLICATIONS.  161 

is  soon  added  a  diminution  in  volume  and  intensity ;  the  dicrotism 
disappears;  the  pulse  becomes  small,  soft,  and  readily  compressible. 

Soon  after  the  appearance  of  the  changes  in  the  pulse,  occasionally 
even  at  the  same  time,  symptoms  of  dilatation  of  the  heart  begin 
to  make  their  appearance.  Their  development  and  tlieir  extension 
rarely  take  place  rapidly  ;  much  more  frequently  they  progress  gradu- 
ally. The  dilatation  is  likely  at  first  to  involve  the  left  side  of  the 
heart.  Far  less  commonly  the  right  side  of  the  heart  also  is  dilated, 
and  then  almost  never  in  considerable  degree.  The  apex-beat  is  at 
times  slightly  enfeebled,  at  other  times  indistinct  and  diffuse,  and  in  the 
most  severe  cases  not  at  all  demonstrable.  If  visible  and  palpable,  it 
will  be  present  in  the  fifth  interspace  in  the  mammillary  line,  rarely 
more  than  two  finger-breadths  beyond  this.  The  dislocation  of  the 
apex-beat  corresponds  with  an  increase  in  the  area  of  cardiac  dulness  to 
the  left,  while  the  dulness  rarely  extends  beyond  the  right  border  of  the 
sternum.  To  the  left  of  the  sternum  and  over  the  sternum  the  upper 
limit  of  cardiac  dulness  is  not  rarely  displaced  upward. 

In  severe  cases  auscultation  discloses  exceedingly  faint  heart-sounds, 
almost  to  the  point  of  complete  disappearance  of  the  systolic  sound. 
The  second  aortic  sound  is  quite  generally  enfeebled,  while  the  second 
pulmonic  sound  at  times  exhibits  distinct  accentuation.  This  may  occur 
without  a  heart-murmur,  particularly  without  a  mitral  murmur,  which 
is,  as  Romberg  appropriately  states,  the  expression  of  an  increase  in  press- 
ure in  the  lesser  circulation  in  consequence  of  deficient  activity  on  the 
part  of  the  left  ventricle.  Under  other  circumstances,  in  association 
with  the  accentuation  of  the  second  pulmonic  somid,  there  is  heard, 
most  distinctly  at  the  apex  of  the  heart  or  with  almost  equal  frequency 
over  the  point  for  auscultation  of  the  pulmonary  artery,  a  systolic 
murmur,  which  is  generally  dependent  upon  relative  mitral  insufficiency. 
It  is  either  a  direct  result  of  dilatation  of  the  left  side  of  the  heart  and 
of  its  auriculoventricular  orifice,  or  of  the  impaired  activity  of  the 
papillary  muscles,  or  of  both. 

However  alarming  these  disturbances  may  at  times  appear,  they 
seem  in  general  to  be  attended  with  little  danger  in  cases  of  typhoid 
fever,  especially  when  compared  with  the  anatomically  similar  myocar- 
ditis of  diphtheria.  In  the  vast  majority  of  cases,  according  to  obser- 
vations made  in  my  clinic,  complete  subsidence  of  the  symptoms  takes 
place,  and  this  is  generally  accomplished  at  the  end  of  the  febrile 
period,  at  times  even  somewhat  earlier.  The  dilatation  also  appears 
usually  not  to  continue  beyond  this  period.  Slight  disturbances  persist 
occasionally  for  a  longer  time  without  serious  injury,  entirely  dis- 
11 


162  TYPHOID   FEVER. 

appearing  eventually.  In  some  cases  which  terminated  ftitally  from 
other  complications,  some  remains  of  the  anatomic  alterations  were  still 
demonstrable. 

Chronic  myocarditis  dependent  upon  typhoid  fever,  with  or  without 
permanent  dilatation,  I  have  as  yet  never  observed  with  certainty.  I 
ku(nv,  however,  that  isolated  instances  have  been  reported  by  others 
(Landouzy  and  Siredey,  Sommer-Henoch),  and  I  believe  that  on  further 
observation  still  others  will  be  added. 

Besides  occurring  at  the  height  of  the  disease,  severe  cardiac  symp- 
toms may  also  make  their  appearance  during  the  stage  of  convalescence 
from  typhoid  fever  without  distinctive  symptoms  having  been  detected 
during  the  febrile  stage  even  in  carefully  observed  cases.  Attention 
has  already  been  called,  in  the  discussion  of  the  state  of  the  pulse,  to 
the  frequency  of  relative  acceleration,  instability,  and  irregularity  of 
the  action  of  the  heart  during  convalescence  Avithout  objectively  demon- 
strable lesions  of  the  heart. 

Cases  do,  however,  occur,  although  but  rarely,^  in  which,  after 
attacks  of  both  severe  and  mild  course,  without  external  provocation, 
without  any  demand  upon  bodily  activity,  with  the  patient  kept  most 
strictly  at  rest  in  bed,  from  one  to  three  weeks  after  defervescence  of 
the  fever  there  may  appear  and  persist  serious  disturbances  of  the  pulse, 
which  occur  otherwise  during  convalescence  only  after  certain  injurious 
influences,  and  then  are  but  transient.  The  marked  acceleration  and 
the  irregularity  of  the  pulse  under  these  conditions  obtrude  themselves 
— far  more  than  during  the  febrile  period — distressingly  upon  the  con- 
sciousness of  the  patient  as  palpitation  of  the  heart,  often  associated  with 
abnomial  sensations  underneath  the  sternum,  in  the  left  lower  mam- 
mary region  and  in  the  epigastrium.  Not  a  few  patients  are  conscious, 
without  feeling  the  pulse,  of  every  intermission  in  the  action  of  the 
heart,  and  are  disturbed  thereby  as  if  by  heart-pains.  There  now  soon 
develop  the  symptoms  of  dilatation  of  the  heart,  in  the  same  way  as  in 
association  with  the  myocarditis  of  the  febrile  period  ;  here  also  the 
left  rather  than  the  right  side  of  the  heart  is  involved,  and  likewise 
not  rarely  with  symptoms  of  relative  mitral  msufficiency. 

The  symptoms  of  this  myocarditis  of  convalescence  may  persist  for 
a  relatively  long  time — up  to  two  months  and  more.  It  is,  however, 
important  and  comforting  to  know  that  the  condition  is  almost  inva- 
riably attended  with  a  favorable  prognosis.     Even  in  those  cases  in 

^  Romberg  properly  emphasizes  this  rarity  in  comparison  with  the  occurrence  of 
myocarditis  during  the  febrile  stage  of  diphtheria. 


SYMPTOMS  AND  COMPLICATIONS.  163 

which  severe  general  circulatory  disturbances  develop/  with  cyanosis 
and  edema  of  the  ankles,  at  times  reaching  half-way  up  the  calves, 
recovery  is  likely  to  take  place.  A.  fatal  termination  is  certainly  excep- 
tional (see  the  case  of  Liebermeister,-  and  that  of  Zaubzer;'  wliich  possi- 
bly also  belongs  in  this  category).  Although  sufficient  post-mortem  data 
bearing  upon  this  myocarditis  of  late  occurrence  are  as  yet  wanting,  it 
is  nevertheless  undoubted  that  the  condition  here  is  likewise  one  of 
severe  parenchymatous  or  interstitial  change  in  the  myocardium ;  and, 
if  a  conclusion  by  analogy  is  permitted,  interstitial  inflammatory  lesions 
will,  as  in  cases  of  diphtheria  and  scarlet  fever,  play  the  most  conspicu- 
ous role.  Whether  the  myocarditic  symptoms  of  the  period  of  conva- 
lescence develop  only  at  this  time,  or  represent  a  manifestation  of 
anatomic  alterations  in  the  heart-muscle  developing  insidiously  at  an 
earlier  period,  cannot  at  present  be  decided  with  certainty.  For  the 
majority  of  cases  the  latter  appears  the  more  probable. 

The  history  of  typhoid  alterations  of  the  myocardium  is  comprehended 
in  that  of  myocarditis  attending  infectious  diseases  generally.  While  pre- 
viously (Laenuec,  Louis)  only  indefinite  conceptions  of  the  anatomic  basis 
of  the  cardiac  disturbances  in  question  were  held,  and  weakness,  softening, 
etc.,  were  spoken  of,  the  fundamental  work  of  Virchow  *  upon  parenchyma- 
tous inflammations  first  brought  clearness  into  this  field.  Subsequently, 
Bottcher,  Waldeyer,  and  Zenker"  continued  the  investigations  into  paren- 
chymatous alterations  in  the  heart  in  cases  of  infectious  disease,  including 
among  others  also  the  typhoid  heart.  They  demonstrated  the  relative  fre- 
quency and  occasional  intensity  of  the  parenchymatous  alterations,  and 
attributed  the  greater  portion  of  the  clinical  symptoms  to  fatty  degenera- 
tion. A  new  fruitful  agitation  was  inaugurated  hj  Hayem  ^  with  the  demon- 
stration of  interstitial  myocarditis.  While  French  investigators  soon  verified 
and  amplified  his  statements,  these  received  the  appreciation  they  deserve 
among  Germans  at  first  only  at  the  hands  of  Ley  den.' 

It  is  to  the  credit  of  Romberg  in  Germany  to  have  emphasized  with 
especial  vigor  the  matters  in  question  in  his  publications  from  my  clinic,* 
to  have  analyzed  them  critically,  and  to  have  supplemented  them  with 
anatomic  and  clinical  facts.  Especially  he  was  the  first  to  point  out  the 
peculiarity  of  the  cardiac  affection  during  convalescence,  and  to  attempt  to 
give  a  clinical  description  of  it. 

Pericarditis  and  endocarditis  are  of  far  less  importance  in  cases  of 
typhoid  fever.  Although  in  the  majority  of  cases  examined  anatomically 
by  Romberg^  small-cell  infiltration  of  the  capillary  walls  and  of  the 

^  The  case  of  general  edema  mentioned  by  Striimpell  (Lehrbuch,  Bd.  i. )  is  probably, 
from  the  extent,  as  well  as  the  localization,  not  attributable  alone  to  stasis  due  to 
cardiac  weakness.  ^  Ziemssen^s  Pathologie,  3d  ed. 

^  Bayrisch.  arztl.  Intelligenzbl.,    1870.  *  Virchow' s  Archiv,  Bd.  ir. 

°  See  the  literature  cited  by  Eomberg,  loc.  cit.  ^  Loc.  cit. 

T  Zeit.f.  klin.  Med.,  Bd.  iv.,  1882.  s  Lqc.  cit. 

^  Loc.  cit. 


16-4  TYPHOID  FEVER. 

smallest  vessels  of  the  deeper  layers  of  the  pericardium  were  present  in 
addition  to  myocarditis,  it  may  still  be  maintained  that  these  processes 
rarely  attain  such  an  uiteusity  and  extent  as  to  give  rise  to  the  clinical 
symptoms  of  pericarditis.  Anatomically,  it  also  happens  occasionally 
that  rather  extensive  fibrinous  deposits  take  place,  at  most  a  slight 
membrane,  especially  surrounding  the  large  vessels,  I  have  observed 
fluid  pcricarditic  effusions  only  with  extreme  rarity  in  cases  of  typhoid 
fever.  In  cases  in  which  I  have  observed  the  development  of  distinct, 
extensive,  long-contiuucd  friction  or  severe  exudative  pericarditis,  the 
conditions  present  were  such  that,  from  other  symptoms  as  well,  they 
had  to  be  referred  to  mixed  infection.  In  cases  of  typhoid  fever  com- 
plicated by  true  septic  processes,  I  have  in  isolated  instances  observed 
even  empyema  of  the  pericardium. 

Scarcely  more  frequent,  at  least  clinically  demonstrable,  is  endocar- 
ditis. According  to  Romberg's  anatomic  investigations,  this  is  one  of  the 
less  common  accompanying  manifestations  of  myocarditis,  and  is  gener- 
ally recognizable  only  microscopically.  Occurring  in  small  foci  that 
occasionally  coalesce,  generally  mural,  beyond  the  range  of  the  valves, 
it  is  situated  at  various  points  of  the  endocardium,  with  especial  fre- 
quency in  the  neighborhood  of  the  cardiac  apex.  The  rare  occurrence 
of  valvular  lesions  of  the  heart  in  the  sequence  of  typhoid  fever  appears 
to  be  dependent  upon  the  rare  anatomic  involvement  of  the  valves. 
Contradictory  reports,  especially  on  the  part  of  earlier  observers,  are  in 
part  probably  attributable  to  the  fact  that  formerly  relative  insuffi- 
ciency as  a  sequel  of  myocarditis  was  not  known,  and  it  was  confused 
with  mitral  endocarditis.  True  valvular  endocarditis  I  have  now  and 
then  observed  in  the  form  of  so-called  ulcerative  endocarditis,  with 
verrucose  deposits  upon  the  valves,  and  -ulcerative  loss  of  tissue,  either 
on  the  aortic  or  the  mitral  valve,  or  on  both  together.  These  were  always 
associated  with  other  septic  symptoms,  especially  multiple  emboli  of  the 
skin,  and  thereby  proved  themselves  to  be  part  manifestations  of  this 
symptom-complex.  Non-septic  endocarditis,  terminating  in  chronic  val- 
vular disease  of  the  heart,  occurred,  as  has  been  stated,  but  exceptionally 
in  my  experience.  Whether  such  a  condition  is  to  be  attributed  to 
the  direct  action  of  the  typhoid  poison  must  be  reserved  for  future 
decision.  In  my  cases  only  the  left  side  of  the  heart  was  aifected,  and, 
with  a  single  exception,  in  which  the  aortic  valves  were  involved,  the 
mitral  valve  alone  was  aifected.  Endocarditis  of  the  right  side  of  the 
heart  has  been  reported  in  1  case  by  Bouchut.  These  cases  of  possibly 
specific  typhoid  endocarditis  develop,  in  my  experience,  at  the  height  of 
the  febrile  stage — in  the  second  and  at  the  beginning  of  the  third  week. 


SYMPTOMS  AND  COMPLICATIONS.  165 

They  cannot  easily  be  distinguished  from  myocarditis  with  relative 
mitral  insufficiency.  Only  the  persistence  of  the  sym])toms,  especially 
the  systolic  murmur  at  the  apex,  and  the  accentuation  of  the  second 
pulmonary  sound,  are  indicative  of  this  endocarditic  character,  and  the 
latter  will  be  decisively  confirmed  by  the  persistence  of  a  valvular  lesion. 
In  one  case  I  believed  myself  justified  in  assuming  the  associated  presence 
of  endocarditis  and  extensive  myocarditis  in  a  young  man  who,  together 
with  endocarditis  followed  by  mitral  insufficiency  and  stenosis,  exhibited 
also  symptoms  resembling  those  of  severe  angina  pectoris,  with  pains 
radiating  to  the  epigastrium,  the  back,  and  the  left  arm.  Quite  excep- 
tionally— so  far  as  I  can  recall  in  but  2  cases,  in  one  a  year  and  in 
another  a  year  and  a  half  after  an  attack  of  typhoid  fever — I  have 
observed  the  appearance  of  the  first  distinct  clinical  symptoms  of  mitral 
insufficiency,  which  had  not  manifested  themselves  during  the  attack  in 
the  form  of  valvular  endocarditis,  but  for  whose  development  no  other 
cause  could  be  elicited.  I  suspect  that  in  these  cases  a  rather  extensive 
mural  endocarditis  was  present,  which  developed  during  the  febrile 
period  of  the  attack  of  typhoid  fever,  and  extended  close  to  but  not  upon 
the  valves.  The  progressive  cicatricial  contraction  that  gradually  took 
place  in  the  process  of  healing  probably  then  involved  portions  of  the 
papillary  muscles  also,  as  well  as  the  points  of  attachment  of  the  valves 
and  the  tendinous  cords,  and  in  this  way  gave  rise  to  secondary  insuf- 
ficiency. Such  occurrences  seem  to  me  to  be  probable  also  in  other 
acute  infectious  diseases ;  especially  do  I  believe  that  valvular  lesions 
of  the  heart  developing  after  apparently  uncomplicated  attacks  of 
scarlet  fever  are  in  part  to  be  explained  in  this  way. 

In  connection  with  the  changes  in  the  myocardium,  a  few  words  may 
be  appropriate  here  with  regard  to  states  of  collapse  in  the  course  of 
typhoid  fever,  especially  since  it  is  still  customary  to  attribute  them 
mainly  to  profound  changes  in  the  heart,  with  the  exception  of  a  few 
cases  due  to  embolism,  especially  of  the  pulmonary  artery.  Sudden 
alarming  attacks  of  weakness  in  cases  of  typhoid  fever,  unfortimately 
not  rarely  terminating  fatally,  were  known  to  earlier  writers  and  were 
given  careful  consideration  decades  ago,  especially  by  Griesskiger^ 
and  Ackermann.^  I  have  observed  them  as  early  as  the  second  week, 
at  the  height  of  the  febrile  stage,  but  still  more  frequently  toward  the 
end  of  the  febrile  period  and  during  the  period  of  convalescence.  They 
may  occur  once  or  several  times  at  irregular  intervals  -  in  the  same 
patient,  at  times  without,  at  other  times  after,  direct  external  influ- 
ences.    Among  these  exciting  factors  belong  emotional  disturbances  and 

^  Arch.  d.  Heilk.^  1861.  ^  Virchoio^s  Archiv,  Bd.  xxv. 


166  TYPHOID  FEVER. 

excessive  ])hysical  activity,  sitting  \\\\  contrary  to  instructions,  expulsive 
eiforts  and  straining  at  stool,  etc.  Those  cases  are  generally  especially 
severe  in  which,  without  demonstrable  cause,  collapse  appears  even 
early,  at  times  during  the  second  week,  and  is  repeated  while  body  and 
mind  are  kept  absolutely  at  rest.     They  frequently  terminate  fatally. 

The  clinical  symptoms  of  collapse  are  those  usual  in  so-called  acute 
cardiac  failure :  })allor  and  lividity,  especially  of  the  face  and  the 
extremities,  drawing  of  the  features,  cold  sweats,  derangement  of  con- 
sciousness, thready,  small,  frequent,  irregular  pulse.  The  anatomic 
investigations  thus  far  made  have  either  yielded  a  negative  result,  or, 
when  they  have  yielded  any  result  at  all,  have  disclosed  parenchyma- 
tous degeneration  of  the  heart,  fatty  degeneration,  and  dilatation.  A 
thorough  study  of  such  cases  by  modern  methods  (Krehl-Romberg)  is 
at  yet  wanting. 

I  would  expressly  emphasize  the  fact  that  I  have  repeatedly  observed 
death  in  collapse  without  any  explanatory  alteration  in  the  body  after 
death,  and  particularly  without  change  in  the  form,  size,  color,  and  con- 
sistency of  the  myocardium.  If  such  cases  are  not  lightly  dismissed 
from  consideration,  but  are  grouped  with  other  threatening  transitory 
circulatory  disturbances  without  clinically  demonstrable  changes  in  the 
heart,  the  question  naturally  arises  :  Are  all  of  these  "  cardiac "  dis- 
turbances, from  the  milder  and  transitoiy  to  those  causing  fatal  col- 
lapse, necessarily  referable  to  the  heart  alone?  This  question  cannot 
be  answered  unconditionally  in  the  affirmative.  Every  unprejudiced 
observer  will  recognize  here  a  deficiency  in  our  knowledge,  which, 
further,  is  applicable  not  alone  to  typhoid  fever,  but  likewise  to  similar 
conditions  associated  with  other  acute  infectious  disaises.  A  number  of 
more  recent  studies  appear  to  shed  light  upon  this  subject,  and  among 
them  especially  that  carried  out  at  my  clinic  by  Romberg^  in  associa- 
tion with  Bruhns  and  Passler.  They  have  shown  that  the  action  of 
toxins  of  the  exciting  agents  of  the  infectious  diseases,  especially  of 
the  pneumococcus,  the  diphtheria-bacillus,  and  the  Bacillus  pyocyaneus, 
is  exerted,  not  alone  upon  the  heart,  but  also  especially  upon  the 
vasomotor  system,  so  that  in  explanation  of  the  symptom-complex  of 
"  profoimd  cardiac  weakness "  paralysis  of  the  vasomotors  is  often  to 
be  invoked. 

The  especial  difficulties  that  attend  experiments  with  the  poison  of 
the  typhoid-bacillus   have   hitherto    prevented   a   special   experimental 

^Address  before  the  Congress  of  Naturalists  at  Liibeek,  1895;  minutes  of  the 
meeting.  Also,  Berlin,  klin.  Woch.,  1895,  Nos.  51  and  52.  Passler  and  Komberg, 
Verhandl.  d.  Congr.  f.  inn.  Med.,  "Wiesbaden,  1896  (address  by  Passler). 


SYMPTOMS  AND   COMPLICATIONS.  Ifj? 

study  of  them.  Nevertheless,  it  is  scarcely  to  be  doubted  that  in 
cases  of  typhoid  fever  a  number  of  circulatory  disturbances  are  in 
whole  or  in  part  to  be  attributed  to  vasomotor  disturbances.  To  what 
extent  this  is  operative,  to  what  deforce  especially  the  ordinary  typical 
circulatory  disturbances  in  the  febrile  stage  of  typhoid  fever  are 
referable  to  such  conditions,  cannot  as  yet  be  stated  absolutely.  Future 
investigation  must  determine  what  part  is  attributable  to  the  heart 
itself,  and  what  to  the  vasomotors,  and  finally  what  to  the  combined 
injurious  influence  of  both. 

Changes  in  the  Blood-vessels,  and  their  Clinical  Mani- 
festations.— Little  is  laiown  with  regard  to  the  arteries  from  cither 
an  anatomic  or  a  clinical  point  of  view.  A  probably  specific  disease  of 
the  arteries — typhoid  arteritis  of  French  investigators — is  especially 
deserving  of  mention.  This  is  possibly  the  principal  cause  of  that 
remarkable  condition,  fortunately  observed  but  rarely,  the  so-called 
spontaneous  gangrene  of  the  extremities  in  the  course  of  typhoid  fever. 

The  tendency  at  present  is  to  consider  the  thrombosis  as  due  to 
an  infective  arteritis ;  and  several  investigators  have  claimed  to  have 
cultivated  the  typhoid-bacilli  from  the  walls  of  the  occluded  arteries. 
More  numerous  and  exact  observations  are  still  needed  m  relation  to 
this  important  point. 

Typhoid  gangrene  is  observed  particularly  in  the  lower  extremities, 
and  almost  always  of  one  extremity  only.  Large  portions  of  the  member 
may  become  gangrenous  :  all  the  toes,  the  entire  foot  up  to  the  knee, 
even  up  to  the  middle  of  the  thigh.  Under  such  circumstances  throm- 
bosis will  be  found  in  the  distribution  of  the  iliac  or  femoral  artery, 
or  only  in  certain  large  branches  of  the  latter,  among  which  the  poste- 
rior tibial  artery  plays  an  especial  rdle. 

This  peculiar  variety  of  gangrene  was,  so  far  as  I  know,  first  described 
by  Bourgeois,^  then  by  Gigon  ''  and  Patry.^  An  interesting  case  of  bilateral 
gangrene  of  the  legs  was  shortly  afterward  described  by  Bachmayr.*  Also, 
Trousseau,  in  his  lectures  at  the  famous  clinic  at  the  Hotel  Dieu,  has  devoted 
a  short  chapter  to  this  manifestation.  Among  more  recent  writers  Potin,* 
Mercier,®  and  Le  Reboulliet ''  may  be  mentioned. 

Keen,^  in  his  admirable  monograph,  has  collected  115  cases  of  gangrene 
in  typhoid  fever  due  to  arterial  thrombosis  or  embolism.  The  earliest 
appearance  of  the  gangrene  was  on  the  fourteenth  day,  the  latest  in  the 
seventh  week.  In  gangrene  of  the  lower  extremities  it  occurred  as  fre- 
quently on  the  right  as  on  the  left  side.     Keen  advises  amputation  in  gan- 

1  Arch.  ghi.  de  Med.,  Aug.,  1857.  2  Union  med.,  Sept.,  1861. 

*  Arch.  ghi.  de  Med.,  Feb.  and  May,  1863. 

*  Verhandl.  d.   Wurzburg.  med.  Oesellsch.,  1868.  *  Loc.  cit. 
^Arch.  de  med.  exper.,  1878.  '  Unio7i  med.,  1878. 

^  Loc.  cit. 


168  TYrnulD   FKVEll. 

grene  of  the  extremities,  but  says  that  as  a  general  rule  it  is  best  to 
wait  for  a  line  of  demarcation  ;  but  operation  should  not  be  deferred  long 
after  its  appearance. 

I  have  personally  observed  typhoid  gangrene  of  the  lower  extremity  in 
2  instances.  In  one  case  gangrene  of  the  foot  and  the  lower  third  of  the 
thigh  developed  in  a  previously  healthy  man,  forty-one  years  old,  in  conse- 
quence of  thrombosis  of  the  popliteal  and  posterior  tibial  arteries  occurring 
in  the  stage  of  the  amphibolic  curve.  In  another  case,'  which  occurred  in  a 
young  girl,  and  terminated  fatally,  the  gangrene  resulted  from  thrombosis  of 
the  iliac  and  femoral  arteries,  which  was  associated  with  thrombophlebitis  of 
the  corresponding  veins,  and  involved  the  foot  and  the  entire  leg  to  the  lower 
third  of  the  thigh.  The  complication  appears  to  be  extremely  rare  in  the 
upper  extremities.  I  have  personally  ol)served  gangrene  of  4  fingers  of  one 
hand  and  the  cutaneous  covering  of  the  back  of  the  hand  in  a  i)atient  who 
escaped  with  his  life.  Gangrene  has  been  noted  in  isolated  instances  in  the 
distribution  of  other  arteries  ;  thus,  in  that  of  the  external  carotid,  in  which 
case  the  auricle,  the  pai'otid  gland,  and  the  integument  covering  them  and 
the  adjacent  soft  parts  became  gangrenous  and  were  exfoliated  (Patry ''). 

Possibly  certain  cases  of  circumscribed  cerebromalacia  occurring  during 
the  terminal  stage  of  typhoid  fever  are  to  be  attributed  to  inflammatory 
thrombosis  of  the  related  cerebral  arteries.  Thus,  in  a  woman,  thirty-seven 
years  old,  I  observed  the  gradual  development  of  right  hemiparesis  with 
aphasia  during  convalescence  from  typhoid  fever  without  antecedent  apo- 
plectiform attack.  The  case,  which  came  under  my  observation  in  con- 
sultation at  a  distance,  terminated  fatally.  The  report  of  the  autopsy  by 
the  attending  physician  mentioned  as  the  cause  of  the  condition  extensive 
softening  of  the  middle  portion  of  the  left  cerebral  hemisphere  in  conse- 
quence of  adhesive  thrombosis  of  the  artery  of  the  fossa  of  Sylvius,  the 
walls  of  which  were,  besides,  considerably  thickened. 

Welch  ^  mentions  4  other'  fatal  cases  of  thrombosis  of  the  middle  cere- 
bral artery  or  its  branches  during  typhoid  fever.  In  the  case  reported  by 
Osier,  severe  convulsions  suddenly  occurred  on  the  ninth  day  of  a  mild  case 
of  typhoid  fever.  Death  occurred  in  teu  hours  after  the  onset  of  tlie  cere- 
bral symptoms.  At  autopsy  there  was  found  tlirombosis  of  branches  of  the 
middle  cerebral  artery,  the  adjacent  brain-substance  being  studded  with 
hemorrhages,  but  not  much  softened. 

In  the  aorta  and  the  large  arterial  trunks  I  have  repeatedly  observed 
extensive  reticular  turbidity  of  the  intima  and  plaques  of  fresh  sclerosis, 
here  and  there  even  dilatation  occurring.  In  one  ease,  occurring  in 
a  man,  thirt}^-five  years  old,  perfectly  healthy  before  the  onset  of  the 
attack  of  typhoid  fever,  the  arch  of  the  aorta,  which  presented  extensive 
reticular  thickening  and  turbidity  of  the  intima,  was  dilated  to  almost 
double  the  normal.  Neither  in  this  case  nor  in  the  others  under  my 
obser%^ation  were  symptoms  present  during  life. 

1  The  case,  which  was  under  my  care  when  I  was  assistant  at  the  St.  Rochiis- 
spitale  in  Mainz,  has  been  reported  by  Masserell  (Deidfch.  Arch.  f.  klin.  Med.,  Bd. 
v.,  S.  445  ff. ).  I  do  not,  however,  agree  with  some  of  the  opinions  expressed  in  this 
paper.  '■'  Loc.  cit. 

"  "Thrombosis  and  Embolism,"  Allbidt's  System  of  Medicine,  vol.  vii.,  London, 
1899. 


SYMPTOMS  AND  COMPLICATIONS.  169 

The  obliterating  visceral  arteritis  previously  mentioned,  described 
by  Landouzy  and  Siredey,'  and  given  undue  prominence  in  France,  is 
of  little  significance  clinically  or  diagnostically.  I  would  emphasize 
expressly  that  in  a  large  number  of  post-mortem  examinations  in  cases 
of  typhoid  fever  in  which  I  noted  the  condition  of  the  coronary  arteries, 
I  never  found  them  diseased.  In  accordance  with  this  observation,  I 
have  also  never  encountered  angina  pectoris  (apart"  from  the  single  case 
already  mentioned),  either  during  the  course  of  an  attack  of  typhoid 
fever  or  among  its  sequels. 

Embolism  of  arteries  of  moderate  or  smaller  size,  of  which  marantic  (?) 
thrombosis  of  the  left  side  of  the  heart,  especially  the  auricle,  is  usually 
the  source,  is  quite  rare.  Emboli  in  the  kidneys  and  the  spleen  are 
relatively  the  most  common,  although  they  are  generally  unattended  with 
distinctive  symptoms.  In  one  case  I  observed  sudden  death  during  con- 
valescence from  typhoid  fever,  in  consequence  of  embolism  of  the  basilar 
artery.  Embolism  of  the  pulmonary  artery,  which,  according  to  Hoff- 
mann, quite  commonly  exhibits  whitish  turbidity  of  the  intima,  follow- 
ing thrombosis  of  the  right  side  of  the  heart  or  the  peripheral  venous 
trunks,  has  already  been  mentioned  as  a  cause  of  sudden  fatal  col- 
lapse. 

The  veins  are  more  frequently  than  the  arteries  the  seat  of  disease  in 
cases  of  typhoid  fever.  Thrombosis  of  the  large  veins  of  the  leg,  with 
the  familiar  symptoms  of  phlegmasia  alba  dolens,  is  not  an  especially 
rare  manifestation  in  the  later  stages  of  typhoid  fever,  especially  during 
convalescence.  Even  at  the  present  day  the  condition  is  often  consid- 
ered the  expression  of  marantic  thrombosis,  and  this  explanation  is 
probably  correct  for  a  portion  of  the  cases.  On  the  other  hand,  the  dis- 
order is  frequently  observed  to  develop  in  previously  healthy,  robust  indi- 
viduals after  a  relatively  mild  attack,  and  in  the  absence  of  particularly 
marked  emaciation.  If,  in  addition,  its  onset  is  attended  with  febrile 
symptoms,  and  often  with  considerable  tenderness  in  the  course  of  the 
crural  and  iliac  veins,  even  with  distinct  symptoms  of  periphlebitis,  the 
possibility  that  the  condition  is  dependent  not  upon  a  simple  thrombo- 
sis, but  upon  an  inflammatory  state  of  the  wall  of  the  vein,  must  be 
taken  into  consideration.  Whether  such  typhoid  phlebitis  is  specific 
and  is  attributable  to  the  direct  activity  of  the  bacillus  of  Eberth  is  not 
yet  certain,  but  it  is  not  improbable  from  the  observations  that  have 
been  made  in  so  many  other  organs.  That  other  micro-organisms  also, 
especially  pyogenic  cocci,  may  participate  in  this  process,  that  therefore 
^  See  the  section  on  Anatomic  Alterations  in  the  Circulatory  Orsrans. 


170  TYrilOID  FEVER. 

a  complicating  phlebitis  in  the  strict  sense  may  occur,  can  scarcely  be 
donbtod  after  the  observations  of  Dnnin.* 

Like  typhoid  arteritis,  phlegmasia  alba  dolens  generally  appears 
upon  one  side.  In  only  2  instances  have  I  observed  the  second 
extremity  bect)me  after  a  time  equally  edematous,  obviously  in  conse- 
quence of  extension  of  the  thrombosis  to  the  lower  portion  of  the 
inferior  vena  cava,  and  thence  to  tlie  other  iliac  vein. 

The  venous  obstructions  in  the  course  of  typhoid  fever  are  under  all 
circmnstances  most  undesirable  complications.  It  is  true  that  recover}"^ 
usually  follows,  but  the  duration  of  the  disease  is  considerably  pro- 
tracted ;  not  rarely  for  as  much  as  two  or  three  months,  and  even  more. 
I  have  not  observed  gangrene  develop  as  a  sequel,  but  now  and  again, 
fortunately  rarel}',  detachment  of  fragments  of  the  thrombus  occurs 
with  fatal  embolism. 

Next  to  thrombosis  of  the  femoral  vein,  phlebitis  and  occlusion  of 
the  saphenous  vein  alone,  or  of  the  popliteal  vein  and  the  deep  veins  of 
the  muscles  of  the  calf,  with  edema  of  the  foot  up  to  the  calf,  and  espe- 
cially with  firm  infiltration  and  considerable  tenderness  of  the  muscles, 
appear  to  be  not  rare.  In  isolated  instances  I  have  obsers'ed  also 
phlebitis  and  periphlebitis  in  old  varicose  dilatations  of  the  veins  of  the 
leg  in  men  and  women  suffering  from  typhoid  fever.  In  my  experi- 
ence, venous  thrombosis  in  the  course  of  typhoid  fever  has  occurred  with 
exceeding  rarity  in  other  portions  of  the  body  than  the  lower  extremi- 
ties. In  one  instance  the  axillary  vein  and  in  another  the  right  sub- 
clavian vein  was  involved.  Besides,  like  many  other  writers,  I  have 
noticed  cases  in  which  phlebitis  and  thrombosis  were  part  manifesta- 
tions of,  or  actually  the  source  for,  general  septicemia  complicating 
typhoid  fever. 

Changes  in  the  Condition  of  the  Blood. — Numerous  state- 
ments with  regard  to  the  condition  of  the  blood  in  cases  of  typhoid 
fever  are  contained  in  the  writings  of  earlier  obsers^ers.  They  refer, 
however,  only  to  the  external  appearances  of  blood  obtained  on  vene- 
section or  from  the  dead  body  or  that  escaping  accidentally.  These 
observations  disclosed  so  little  that  for  a  long  time  the  study  of  the 
blood  was  altogether  neglected.  With  the  adoption  of  improved 
methods,  such  investigations  have  recently  been  resiuned  with  more 
success.  The  moi'jihology  of  the  blood  and  certain  chemical  changes 
in  it,  particularly  the  behavior  of  the  hemoglobin,  have  been  studied, 
and  special  consideration  has  been  given  to  bacteriologic  investigation. 

Changes  in  the  Formed  Elements  of  the  Blood. — With   regard 

^  Deutsch.  Arch.  f.  klin.  Med.^  Ed.  xxxix.,  Hefte  3  u.  4. 


SYMPTOMS  AND   COMPLICATIONS.  171 

to  the  red  blood-corpuscles,  these  but  rarely  exhibit  marked  changes 
in  form,  size,  and  color,  but  their  enumeration  has  yicjlded  not  uninter- 
esting results.  While  earlier  writers,  especially  Malasse/  and  Hayem, 
were  unable  to  demonstrate  a  reduction  in  their  number,  most  recent 
writers  have  found  that  in  the  majority  of  cases  the  number  of  red  cor- 
puscles undergoes  slowly  progressive  reduction  during  the  febrile  period. 
Evidence  in  support  of  this  statement  is  contained  in  the  articles  of 
Zaslein,^  Tumas,^  Halla,^  and  Leichtenstem,*  and  as  a  result  of  obser- 
vations made  in  my  clinic  I  am  in  accord  with  them.  We  also  observed '' 
reduction  in  the  number  of  red  cells,  even  from  the  beginning  of  the 
febrile  period.  This  reduction  is  generally  slight  in  young,  robust 
men,  so  that  the  number  still  equalled  4,000,000  or  somewhat  more, 
while  in  women  and  debilitated  individuals  a  reduction  to  3,000,000  or 
even  somewhat  less  occurred.  Thayer,^  from  an  analysis  of  all  blood- 
counts  on  typhoid  patients  in  the  Johns  Hopkins  Hospital  during  the 
past  eleven  years,  states  that  the  average  loss  is  about  1,000,000  per 
c.mm.  The  reduction  continues  to  increase  until  toward  the  end  of 
the  febrile  period,  and  even  into  the  afebrile  period.  In  cases  of  long 
duration,  however,  regeneration  may  begin  well  before  the  end  of  defer- 
vescence. During  convalescence,  usually  from  two  to  three  weeks  after 
defervescence,  the  number  is  likely  to  return  to  the  normal.  It  appears, 
however,  that  the  number  of  red  blood-corpuscles  physiologically  normal 
to  the  individual  is  but  slowly  attained.  We  have  failed  to  find  the 
normal  number  in  patients  who  had  been  free  from  fever  for  even 
seven  weeks.  With  the  onset  of  relapses,  the  number  of  red  blood-cor- 
puscles will  often  be  found  smaller  than  during  the  first  febrile  period 
of  the  disease.  This  is  obviously  due  to  the  cumulative  effects  of  the 
two  periods. 

An  interesting  circumstance  mentioned  by  various  observers  consists 
in  occasional  variations  in  the  number  of  red  blood-corpuscles  in  the 
same  individual  during  the  course  of  the  fever.  We  have  observed 
a  transitory  increase  in  the  number  to  the  extent  of  500,000,  and  even 
of  1,000,000.  Probably  under  such  circumstances  there  is  not  a  real, 
but  only  a  relative  increase,  in  consequence  of  variations  in  density — 
that  is,  in  the  amount  of  water  contained  in  the  blood.  Thus,  we 
have  noticed  such  an  apparent  increase  in  the  number  of  red  blood- 

^  Inaug.  Diss.,  Basel,  1881.  ^  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  xli. 

^  Zeit.f.  Heilk.,  Bd.  iv. 

*  Untersuchungen  uber  d.  Hdmoglohingehalt  des  Blutes  im  gesunde^i  u.  kranken 
Zustande,  Leipsic,  1871. 

*  Kolner,  Inaug.  Diss.,  Leipsic,  1896. 

*  Johns  Hopkins  Hosp.  Rep.,  vol.  viii. 


172  TYPHOID  FEVER. 

corpuscles  after  profuse  sweatiug.  Grawitz  ^  lias  observed  the  specific 
gravity  of  the  blood,  and  therefore  its  density,  increase  after  cold  baths, 
owing,  as  he  correctly  believes,  to  the  effect  which  stimulation  of  the 
vasomotor  nervous  system  exerts  upon  the  water-content  of  the  blood. 
Possibly  statements  as  to  the  relative  increase  in  the  number  of  red 
blood-corj)uscles  at  the  beginning  of  the  febrile  jieriod  arc  attributable 
to  influences  that  at  times  give  rise  to  a  reduction  in  the  fluids  of  the 
blood. 

The  reduction  in  the  percentage  of  hemoglobin  in  the  blood  during 
the  febrile  period  appears  to  correspond  with,  but  in  no  event  to  exceed, 
that  in  the  number  of  red  blood-corpuscles  (Quincke).  That  this  reduc- 
tion, however,  is  not  constant,  and  by  no  means  considerable,  is  shown 
by  the  negative  observations  of  Leichtenstern.  In  my  clinic,  average 
reductions  to  from  80  to  75  per  cent,  have  been  observed,  rarely  lower 
figures.  In  the  afebrile  period,  especially  during  the  first  weeks  of  this 
period,  all  observers,  including  Leichtenstern,  observed  a  lower  percent- 
age of  hemoglobin  than  during  the  febrile  period,  this  again  cor- 
responding with  the  greatest  reduction  in  the  number  of  red  blood- 
corpuscles  which  usually  occurs  at  this  stage.  Laache  ^  states — and  in 
this  we  can  agree  with  him  upon  the  basis  of  personal  experience — that 
during  convalescence,  while  the  number  of  red  blood-corpuscles  is  again 
in  process  of  increase,  a  further  reduction  in  the  percentage  of  hemo- 
globin may  take  place.  It  probably  usually  happens  that  where  the 
anemia  has  been  appreciable  the  return  of  the  hemoglobin  to  the  normal 
is,  as  in  most  secondary  anemias,  more  gradual  than  that  of  the  red 
blood-corpuscles. 

In  comparison  with  what  is  known  concerning  the  leukocytes  in 
other  infectious  diseases,  the  state  of  the  white  blood-corpuscles  during 
typhoid  fever  is  striking.  While  in  the  majority  of  acute  infectious 
diseases  the  white  blood-corpuscles  are  found  increased  at  the  height  of 
the  attack,  this  increase  is  wanting  with  great  constancy  in  cases  of 
typhoid  fever ;  a  diminution,  which  may  even  be  veiy  considerable,  is 
often  present  (Halla,^  Tumas,*  von  Limbeck,^  Rieder,^  Grawitz,^  Naegeli,^ 
Thayer  ^).  It  even  happens,  as  Rieder  showed,  that,  with  increase  in  the 
symptoms  of  the  disease,  with  marked  elevation  of  the  temperature, 
and  with  the  onset  of  recrudescences,  the  number  of  white  blood-cor- 
puscles undergoes  still  further  reduction.     We  have  arrived  at  the  same 

1  Klin.  Pathol,  d.  Bhdes.  ■  ^  Path.  d.  Blutes. 

3  Loc.  cit.  *  Loc.  cit.  ^  Zeit.  f.  Heilk.,  Bd.  x. 

*  Beitrage  zur  Kenntniss  der  Leukocytose  und  vercoandter  Ziistdnde  des  Bhites, 
Leipsic,  1892. 

^  Loc.  cit.  8  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  Ixvii.  ^  Loc.  cit. 


SYMPTOMS  AND  COMPLICATIONS  173 

conclusions  as  the  observers  named,  and  can  confirm  especially  the 
occurrence  of  increased  reduction  in  the  number  of  the  leukocytes  with 
exacerbations  of  the  disease. 

In  uncomplicated  cases  during  the  febrile  stage  we  have  found 
from  9000  down  to  2000  white  blood-corpuscles  in  the  cubic  millimeter. 
Exacerbations  of  the  disease  not  rarely  gave  rise  to  a  further  reduction 
of  1000.  Counts  above  10,000  are  rare,  and  usually  indicate  the  onset 
of  some  complication  or  the  effect  of  some  foreign  influence.  Thayer 
has  shown  that  cold  baths  cause  an  immediate  transient  mcrease  in  the 
number  of  leukocytes  in  the  peripheral  circulation.  Complications  with 
such  conditions  that  ordinarily  give  rise  to  leukocytosis  are  attended 
with  an  increase  in  the  number  of  white  corpuscles  to  the  normal  and 
above.  Thus,  in  a  case  of  intercurrent  pneumonia  11,600  were  counted, 
and  with  the  development  of  an  abscess  over  the  sacrum  4500,  as 
compared  with  2400  previously. 

As  to  the  effect  of  other  complications  upon  the  leukocytes,  it  may 
be  said  that  hemorrhage  may  exercise  little  or  no  influence,  though  often 
there  is  a  tendency  toward  a  leukocytosis  reaching  its  maximum  twelve 
to  twenty-four  hours  after  the  hemorrhage  has  occurred.  Thrombosis 
and  phlebitis  are  associated  with  a  leukocytosis.  The  behavior  of  the 
white  corpuscles  in  perforation  is  of  great  importance,  especially  in 
relation  to  early  diagnosis.  Thayer  concludes  from  quite  frequent  and 
accurate  counts  on  8  cases  that  perforation  of  the  bowel  is  usually  fol- 
lowed by  an  increase  in  the  number  of  leukocytes  m  the  peripheral  cir- 
culation. This  may  be  considerable  or  only  sKght,  and  appreciable  only 
in  comparison  with  previous  counts.  Not  infrequently,  however,  there 
is  an  absence  of  increase ;  even  a  diminution  in  the  number  of  leuko- 
cytes may  occur,  the  latter  being  generally  an  indication  of  the  malig- 
nity of  the  infection  or  the  prostration  of  the  patient. 

No  distinct  difference  in  the  reduction  in  the  number  of  the  white 
corpuscles  in  accordance  with  the  severity  of  the  attack  appears  to  occur, 
at  least  not  in  such  a  degree  that  prognostic  conclusions  can  be  drawn. 
In  my  clinic  recovery  ensued,  for  instance,  in  a  case  in  w^hich  a 
reduction  to  1400  occurred.  While,  therefore,  no  special  prognostic 
significance  can  be  attached  to  enumeration  of  the  white  blood- 
corpuscles,  the  procedure  is,  nevertheless,  not  without  significance  in 
differential  diagnosis,  particularly  with  regard  to  diseases  that  are 
constantly  attended  with  marked  increase  in  the  number  of  white 
blood-corpuscles,  and  that  occasion  difficulties  clinically.  Pneumonia, 
septic  processes,  and  cerebrospinal  meningitis  may  be  mentioned  in  this 
connection. 


174  TYPHOID  FEVER. 

It  is  surprising  that  an  observer  like  Virchow  reports  an  increase  in  the 
leukocytes  in  typhoid  fever,  and  the  question  ari.^es  whether  his  observations 
are  referable  to  the  initial  stage.  French  investigators,  as,  for  instance, 
Bonne,'  have  found  considerable  increase  during  the  first  week,  and  only 
subsequently  a  rapid  decrease  in  the  number  of  white  blood-corpuscles. 

During  the  period  of  convalescence  the  number  of  leukocytes  appears 
again  to  increase  sloAvly  ;  and  in  debilitated  persons,  according  to  our 
observations,  more  slowly  than  in  robust  individuals,  in  whom  often  a 
return  to  the  normal  may  be  noted  during  defervescence  or  during  the 
first  afebrile  days.  In  isolated  instances,  Kolner  ^  relates  having  ob- 
served during  convalescence,  without  especial  apparent  cause,  transitory 
increase  in  the  number  of  white  blood-coipuscles  above  the  physiologic, 
up  to  12,000,  in  one  instance  even  up  to  17,500.  This  observation  is 
supported  in  a  remarkable  manner  by  a  similar  observation  of  I^aaehe. 

As  to  the  variations  which  occur  in  the  relative  number  of  the 
diifereut  varieties  of  leukocytes,  Thayer^  says  there  are  three  main 
changes,  and  other  authorities  agree  with  him  in  the  general  statements 
(see  Naegeli  ^). 

(1)  There  is  a  progressive  diminution  in  the  percentage  of  poly- 
mo  rphon  uclears. 

(2)  There  is  a  progressive  increase  in  the  percentage  of  mononuclear 
forms,  the  increase  being  mainly^  in  the  large  mononuclear  varieties. 

(3)  A  constantly  small  percentage  of  eosinophilic  cells  occurs. 
Naegeli  thinks  that  the  eosinophiles  usually  entirely  disappear  during 

the  height  of  the  fever,  and  that  their  persistence  is  a  very  fa\'orable 
prognostic  sign. 

Bacteriology  of  the  Blood. — Since  the  time  of  Gaffky,  numerous 
observers  have  devoted  themselves  to  the  investigation  of  the  blood  for 
micro-organisms,  particularly  typhoid-bacilli.  Gaff'ky  himself,  as  is 
known,  obtained  negative  results  in  his  own  investigations  in  this  direc- 
tion. Later  investigators  have  directed  their  studies  in  part  to  the 
examination  of  the  blood  obtained  from  some  convenient  part  of  the 
body,  generally  the  tip  of  the  finger,  and  in  part  to  an  investigation  of 
that  obtained  from  certain  parts  of  the  body  the  seat  of  specific  lesions, 
especially  the  roseolse.  The  results  are  widely  divergent,  and  in  part 
are  markedly  contradictory.  While,  for  instance,  Meissel'^  foimd 
typhoid-bacilli  in  the  blood  constantly  in  9  cases  examined  for  this 
purpose,  others,  as,  for  instance,  Almquist^  and  Silvestrini,^  have  been 
able  to  demonstrate  them    only    in  isolated    instances.      Observers  of 

1  These  de  Paris,  1876.  ^  Loc.  cit.  ^  Loc.  cit. 

*  Loc.  cit  5  ifrign.  nied.  WocJu,  1886,  Nos.  21  and  23. 

*  Goteborg,  1885.  '  Riv.  gen.  di  din.  med.,  1892. 


SYMPTOMS  AND  COMPLICATIONS.  175 

especial  skill,  such  as  Frankcl  and  Simmonds/  also  Lugatello^  and 
Seitz,  have,  however,  just  as  did  Gaffky,  invariably  obtained  negative 
results. 

Newer  work  with  better  methods  has,  however,  shown  that,  instead 
of  typhoid-bacilli  occurring  only  exceptionally  in  the  blood,  they  probably 
are  present  in  every  case  during  some  stage  of  the  disease,  and  can  be 
demonstrated  in  a  majority  of  all  the  cases  if  proper  methods  in  making 
cultures  are  employed.  Cole,^  by  using  considerable  amounts  of  blood  and 
diluting  very  largely  in  liquid  media,  was  able  to  demonstrate  the  bacilli 
in  11  out  of  15  cases  examined.  In  6  of  these  cases  the  bacilli  were 
cultivated  from  the  blood  before  the  Widal  test  was  positive,  so  that  the 
method  has  considerable  diagnostic  importance.  These  results  have 
since  been  confirmed  on  numerous  other  cases  at  the  Johns  Hopkins 
Hospital. 

Schottmiiller  ^  has  lately  obtained  the  bacilli  from  the  circulating 
blood  of  40  out  of  50  cases  examined  by  him.  Aeurbach  and  linger  ^ 
report  positive  results  in  7  out  of  10  cases,  and  Castellani''  has  culti- 
vated the  bacilli  from  the  blood  of  12  out  of  14  cases. 

In  the  same  way  as  with  regard  to  examinations  of  the  blood  gen- 
erally, observers  differ  also  with  reference  to  the  presence  of  bacilli  in 
the  typhoid  roseolse.  It  was  hoped  at  first  that  the  study  of  these 
structures  might  yield  important  results.  It  would  undoubtedly  be  of 
great  diagnostic  significance  to  be  able  to  demonstrate  the  specific  bacteria 
in  the  frequent  characteristic  alterations  in  the  skin.  These  hopes  have, 
however,  not  been  fully  realized.  It  is  true  Neuhaus  ^  believed  that  he 
had  demonstrated  them  in  more  than  half  of  the  cases  examined  by 
him  (in  9  of  15  patients)  in  blood  from  the  roseolse.  Opposed  to  him, 
however,  are  the  entirely  negative  results  of  the  observers  previously 
mentioned,  Frankel  and  Simmonds,  Seitz,  Lugatello,  Gaffky  and 
Janowski.^ 

However,  within  the  past  few  years  the  frequent,  probably  constant, 
presence  of  typhoid-bacilli  in  the  rose-spots  has  been  demonstrated  by 
Neufeld,  Curschmann,  and  Richardson  in  32  out  of  40  cases  from  which 
cultures  were  made  by  these  observers.  E.  Frankel  has  also  demon- 
strated their  presence  in  sections  of  the  rose-spots  (see  section  on  Dis- 
cussion of  the  Individual  Features — Roseola). 

^  Loc.  cit.  2  Boll.  d.  Roy.  Acad,  di  Genova,  1886.  ^  Loc.  cH. 

*  Bull.  Johns  Ho]) kins  Hosp.,  vol.  xii.,  No.  124. 

^  Deutsch.  med.   Woch.,  Aug.  9,  1900. 

6  Ibid.,  Dec.  6,  1900.  ^  Rif.  med.,  vol.  i.,  Nos.  6  and  7. 

8  Berlin,  klin.  Woch.,  1886,  Nos.  6  and  24.       »  Loc.  cit. 


176  TYPHOID  FEVER. 

In  addition  to  examination  of  tlie  oivcnlatiug  blood  and  the  roseolae, 
attention  has  been  directed  also  to  the  blood  of  the  s|)leen.  Positive 
residts  conld  most  reasonably  be  expected  from  this,  as  it  is  \vell  known 
that  examination  of  the  splenic  pulp  after  death  for  bacilli  almost 
always  yields  positive  results.  Among  the  first  who  obtained  positive 
results  from  the  examination  of  the  blood  of  the  s])leen  dnring  life 
are  Chautemesse  and  W'idal/  Kedenbacher/  Philipowicz/^  and  E. 
Neisser.*  Attempts  were  made  to  ntilize  these  findings — and  Neisser 
had  this  especially  in  view — for  pnrposes  of  early  diagnosis.  I  believe 
that  there  are  serious  objections  to  this  practice.  In  the  first  place, 
the  results  in  question  are  by  no  means  constant,  as  the  observations  of 
Stagnitta,®  for  example,  show ;  and  even  if  this  A\ere  not  the  case,  the 
danger  of  the  procednre  would  stand  in  the  way  of  its  employment. 
One  need  but  think  of  the  tensely  distended  spleen  often  observed  after 
death,  with  the  stretched  and  thinned-out  capsule,  and  also  of  the 
tendency,  which  is  by  no  means  slight,  to  spontaneous  rupture,  and  one 
will  not  escape  the  fear  that  puncture  of  the  spleen  during  life  may 
readily  result  in  rupture  and  dangerous  hemorrhage.  I  have  never 
been  able  to  make  up  my  mind  to  perform  the  operation.^ 

SPLEEN  AND  THYROID  GLAND. 

Bnlargfement  of  the  Spleen. — Although  recent  enlargement 
of  the  spleen,  obviously  a  manifestation  of  the  infectious  process,  is 
observed  in  all  infectious  diseases,  nevertheless,  apart  from  malarial 
fevers  and  septic  diseases,  splenic  tumor  is  in  no  disease  of  as  great  diag- 
nostic significance  as  in  tj^phoid  fever.  This  fact  has  even  given  rise  to 
exaggeration  of  the  value  of  the  symptom.  Some  physicians  will  not 
venture  a  diagnosis  of  typhoid  fever  at  all  without  the  demonstration  of 
enlargement  of  the  spleen.  In  addition  to  the  frequency  of  enlarge- 
ment of  the  spleen,  its  early  occurrence,  its  relatively  long  duration,  and 
its  constant  reappearance  in  recrudescences  and  relapses  are  especially 
indicative  of  typhoid  fever. 

The   frequency   of  typhoid   enlargement   of  the   spleen    in   general 

'  Loc.  cit.  2  Zeit.f.  klin.  Med.,  Bd.  xix. 

»  Wien.  med.  Blatter,  1886,  Nos.  6  and  7.  *  Zeit.f.  klin.  Med.,  Bd.  xxiii. 

*  Rif.  med.,  1890. 

®  Also,  Neisser  (Haedke,  "Die  Diagnose  des  Abdominaltyphus  und  Widal's 
Serumdiagnostisches  Verfahren,"  Deiitsch.  med.  Woch.,  1807,  No.  2)  has  recently 
reported  that  at  present  he  performs  puncture  of  the  spleen  for  diagnostic  purposes 
only  in  the  rarest  cases,  since  he  had  found  on  post-mortem  examination  of  one 
patient  on  whom  the  operation  had  been  performed  a  fine  tear,  0.5  cm.  long,  in  the- 
capsule  of  the  spleen,   and  100  grams  of  blood  in  the  abdominal  cavity. 


SYMPTOMS  AND  COMPLICATIONS.  177 

caunot  be  estimated  with  certainty  from  the  results  of"  clinical  examina- 
tion. As  will  be  more  fully  discussed  later,  its  demonstration  at  the 
bedside  is  attended  with  various  difficulties,  so  that,  if  a  trustworthy 
conclusion  is  desired,  the  aid  of  anatomic  observation  must  be 
invoked.  In  young,  robust  individuals,  when  death  occurs  at  the 
height  or  toward  the  end  of  the  disease,  even  a  short  time  after  the 
onset  of  defervescence,  more  or  less  recent  hyperemia  of  the  spleen  is 
rarely  wanting.  In  conformity  with  clinical  experience,  however,  and 
to  this  extent  also  available  in  examination  and  diagnosis,  is  the  fact 
that  in  cases  of  typhoid  fever  moderate  sized  splenic  tumors  are  far 
more  frequent  than  especially  large  ones.  Enlargement  of  the  organ 
to  double  the  normal  or  to  two  and  a  half  times  the  normal  is  the  rule, 
three  times  the  normal  volume  being  somewhat  less  common.  The 
maximum  size  has  probably  been  reported  by  Rokitansky  as  six  times 
the  physiologic. 

The  enlargement  of  the  spleen  is  likely  to  be  greatest  at  the  height 
of  the  disease,  while  at  the  commencement  and  in  the  period  of  steep 
curves  or  on  the  first  afebrile  days  its  volume  is  less.  In  the  later 
stages  of  convalescence  enlargement  of  the  spleen  is  present  only  excep- 
tionally. 

Undoubtedly,  the  mean  size  of  the  splenic  enlargement  varies,  like  many 
other  symptoms  of  typhoid  fever,  in  different  epidemics.  I  have  noted 
periods  in  which,  anatomically  and  clinically,  the  enlargement  of  the  spleen 
was  slight ;  and  others,  for  instance  the  Hamburg  epidemic  of  1886-1887,  in 
which  an  unusual  number  of  large  splenic  tumors  were  observed.  Of  300 
successive  autopsies  of  which  I  have  notes,  there  were  found  exceedingly 
large  tumors  in  127,  and  tumors  of  moderate  and  considerable  size  in  173. 
In  no  case  was  enlargement  of  the  spleen  wanting.  In  Leipsic,  on  the  other 
hand,  among  211  autopsies  on  cases  of  typhoid  fever,  there  were  observed 
exceedingly  large  tumors  in  45,  tumors  of  moderate  size  in  115,  small 
tumors  in  21,  and  absence  of  splenic  enlargement  in  30.  The  table  of 
Hoffmann  should  also  be  consulted. 

When  enlargement  of  the  spleen  is  wanting  during  the  febrile  period, 
this  is  dependent  in  the  majority  of  cases  upon  special  conditions.  Thus, 
in  advanced  life,  or  in  young  or  middle-aged  individuals  when  the 
attack  of  typhoid  fever  has  been  preceded  by  diseases  attended  with 
marked  emaciation,  enlargement  of  the  spleen  is  frequently  wanting 
throughout  the  entire  course  of  the  disease  and  upon  post-mortem 
examination.  The  conditions  last  named  give  rise  rather  to  atrophy 
of  the  spleen,  and  if  then  infectious  enlargement  of  the  organ  takes 
place  at  all,  this  will  be  just  sufficient  to  restore  it  to  its  physiologic 
size. 

At   times,    antecedent   disease  of    the    spleen   itself    may  prevent 

12 


178  TYPHOID  FEVER. 

enlargement  of  the  org-an  in  typhoid  i'evor.  Thns,  the  splenic  tissue 
may  be  the  seat  of  cicatricial  change,  in  consequence  of  previous  large 
or  multi])le  infarction  ;  or  its  elasticity  may  be  impaired  by  chronic 
ditJ'use  connective-tissue  hyj)erplasia  or  by  widespread  inflammatory 
thickening  of  its.  capsule.  Perhaps  in  the  conditions  last  named  may 
reside  the  explanation  of  my  observation  that  when  typhoid  fever  occurs 
for  the  second  or  the  third  time  in  the  same  patient  enlargement  of  the 
spleen  is  absent  with  remarkable  frequency.  Finally,  it  should  be 
mentioned  that  profuse  acute  hemorrhage  may  cause  rapid  diminution  in 
the  size  of  an  enlarged  s])leen.  Especially  when  death  results  from 
profuse  intestinal  hemorrhage  is  the  spleen  found  not  rarely  of  normal 
size,  but  remarkably  pale,  flabby,  and  wrinkled. 

The  absence  of  splenic  tumor  without  demonstrable  cause  is,  during 
the  febrile  stage  of  the  disease,  an  extremely  rare  anatomic  condition.  I 
have  myself,  it  is  true,  exceptionally  made  this  observation  in  yoimg 
persons,  but  then  the  parenchyma  of  the  spleen  was  usually  at  least 
abnormally  hyperemic,  soft,  and  bulging,  thus,  in  a  condition  of  acute 
transition ;  in  2  cases,  in  fact,  recent  considerable  extravasations  of 
blood  were  found  in  the  spleen. 

Among  577  autopsies  (Hamburg,  Leipsic),  I  found  absence  of  splenic 
enlargement  noted  in  49.  If  from  these  cases  are  deducted  those  in  which 
one  of  the  factors  named  explained  the  condition,  there  remain  but  9 — 1.6 
per  cent,  of  all  cases — in  which  enlargement  of  the  spleen  was  wanting 
during  the  febrile  stage  without  demonstrable  cause. 

The  idtimate  cause  of  typhoid  enlargement  of  the  spleen  and  the 
special  conditions  for  its  occurrence  are,  as  yet,  unknown.  The  earlier 
assumption  that  the  pyrexia  alone  was  the  responsible  factor  must  cer- 
tainly be  rejected.  Undoubtedly,  the  development  of  the  typhoid 
enlargement  of  the  spleen  stands  in  most  intimate  relation  with  the 
bacillus  of  Eberth  and  its  toxins.  In  favor  of  this  view,  perhaps,  is  the 
almost  constant  presence  of  bacilli  in  the  spleen  after  death,  and  also 
the  successful  demonstration  of  them  by  puncture  of  the  spleen  during 
life,  to  which  reference  has  already  been  made. 

The  splenic  tumor,  as  has  been  said,  is  a  manifestation  of  the  febrile 
stage  of  the  disease.  Neither  the  time  nor  the  degree  of  its  development 
appears  to  bear  any  relation  to  the  severity  or  the  character  of  the  febrile 
course.  Marked  enlargement  of  the  spleen  is  observed  even  early  in 
the  mildest  cases  of  typhoid  fever  with  a  short  remittent  or  intermittent 
febrile  course,  and  also  in  the  protracted  cases  with  high  fever.  I 
have  generally  observed  enlargement  of  the  spleen  even  in  cases  of 
typhoid  fever  almost  unattended  with  fever.     With  the  onset  of  con- 


SYMPTOMS  AND   COMPLICATIONS.  179 

valescence — that  is,  with  reduction  in  the  fever — invohition  of  the 
splenic  tumor  usually  begins.  At  the  close  of  the  third  or  during  the 
fourth  week  it  is  then  no  longer,  demonstrable  in  cases  that  pursue  an 
ordinary  course.  The  greatest  degree  of  splenic  enlargement  is  exhibited 
generally  in  the  second  up  to  the  beginning  of  the  third  week ;  only  in 
especially  protracted  cases  is  it  likely  to  be  deferred  to  a  later  period. 
The  time  for  the  commencement  of  the  splenic  swelling  is,  from  anatomic 
and  clinical  knowledge,  on  the  average  the  middle  or  the  second  half 
of  the  first  week.  In  the  last  days  of  the  first  week  its  clinical  demon- 
stration is  quite  frequently  possible. 

Premature  reduction  in  the  size  of  the  enlarged  spleen  during  the 
febrile  stage  is  exceptional.  This  generally  occurs  only  under  special 
conditions,  as  has  been  mentioned ;  in  connection  with  profuse  hemor- 
rhage, now  and  again  also  after  especially  profuse  diarrhea.  During 
the  stage  of  steep  curves  involution  of  the  splenic  tumor  is  more  fre- 
quent, as  occasionally  can  be  confirmed  anatomically.  It  should  be 
noted,  however,  that  softening  of  the  spleen  with  preservation  of  its 
size,  as  is  peculiar  to  the  stage  mentioned,  may  clinically  be  readily 
mistaken  for  actual  diminution  in  size. 

Abnormally  protracted  persistence  of  the  splenic  tumor  occurs  almost 
exclusively  in  cases  that  otherwise  also  pursue  a  protracted  course. 
In  any  event,  it  should  be  borne  in  mind  that  so  long  as  the  typhoid 
splenic  tumor  is  demonstrable,  the  disease  cannot  be  considered  as 
having  terminated.  This  is  true  even  for  patients  in  whom  the  fever 
has  already  disappeared.  They  are  still  under  the  influence  of  the 
infection,  and  are  threatened  especially  by  the  danger  of  relapse.  Also, 
when  the  splenic  tumor  has  already  undergone  involution,  renewed 
increase  in  its  size  is  indicative  of  the  advent  of  a  recrudescence  or  a 
relapse,  often  occurring  even  before  elevation  of  temperature  has  taken 
place.  Mention  of  the  occurrence  of  splenic  tumor  at  an  abnormally  early 
period  should  not  be  omitted  here.  I  have  observed  several  cases  in 
which  enlargement  of  the  spleen  was  with  certainty  demonstrable  clin- 
ically even  before  the  fourth  day  of  the  disease.  Splenic  tmnors  are 
probably  not  so  rare  even  in  the  period  of  incubation  as  is  generally 
assumed ;  there  is  not  often  reason  for  examination  at  this  time,  for 
examination  is  undertaken  only  when  complaint  of  local  symptoms  is 
made. 

I  have  been  able  in  2  cases  to  determine  the  presence  of  enlargement  of 
the  spleen  during  the  period  of  incubation.  The  first  occurred  in  a  woman, 
twenty-five  years  old,  who  complained  one  morning  of  pain  in  the  left  side 
on  fastening  her  clothing,  which  had  developed  during  the  night,  and  a  cause 
for  which  was  found  in  a  recent  splenic  tumor,  to  which  the  commencement  of 


180  TYPHOID  FEVER. 

the  febrile  syniptoius  was  aikled  three  days  hiter.  The  other  patient,  an 
apparently  healthy  lad,  fourteen  years  old,  complained  suddenly  in  walking 
and  running  of  a  sharp  pain  in  the  left  side.  On  examination  he  was  found 
free  from  fever,  and  without  roseolae  and  diarrhea.  At  the  same  time, 
however,  a  distinctly  palpable,  tender  si)lenic  tumor  was  jireseut.  In  the 
course  of  two  days  chilliness  appeared  for  the  first  time,  with  the  commence- 
ment in  the  elevation  of  temperature.  Tlie  case  jiursued  a  severe,  tedious 
course,  with  two  relapses,  between  which  the  swelling  of  the  spleen  disap- 
peared. Similar  observations  have  been  reported  also  by  others.  I  need 
refer  only  to  the  case  of  Friedrich  mentioned  in  his  famous  treatise  upon 
acute  splenic  tumor.' 

In  spite  of  the  anatomic  constancy  of  enlargement  of  the  spleen,  its 
demonstration  clinically,  as  has  been  mentioned,  can  fiv([uently  not  be 
made  either  for  a  short  or  longer  time,  if  exact  landmarks  only  are 
observed.  This  is  dependent  in  part  upon  the  fact  that  dnring  various 
periods  and  epidemics  the  average  size  of  the  splenic  tumor  varies  con- 
siderably, and  in  part  upon  the  fact  especially  that  examination  for 
splenic  enlargement  in  the  individual  case  is  attended  with  not  a  few 
general  and  individual  difficulties.  A  general  idea  of  the  statistics  in 
this  connection  may  be  obtained  from  the  following  estimates  made  at 
Hamburg  and  Leipsic.  In  the  year  1887,  among  2205  cases  in  the 
Hamburg  Hospital,  splenic  tumor  was  demonstrated  in  1859 — 84.3  per 
cent. ;  was  palpable  in  34.2  per  cent.  ;  and  uncertain  or  wanting  in  346 
— 15.7  per  cent.  This  epidemic  was  characterized,  as  the  anatomic 
observations  showed,  by  the  frequency  of  large  splenic  tumors. 

In  Leipsic,  among  1626  cases,  splenic  tumor  was  demonstrable  in 
1051 — 69.4  per  cent. ;  was  uncei'tain  or  not  demonstrable  in  575 — 
30.6  per  cent.  These  data  are  obtained  from  statistics  covering  a  period 
of  more  than  thirteen  years,  and  collected  by  different  observers.  The 
number  of  cases  in  which  enlargement  of  the  spleen  was  uncertain  or  not 
demonstrable  appears  remarkably  large  in  comparison  with  the  corre- 
sponding Hamburg  figures.  According  to  my  general  experience,  I 
would  believe  that  throughout  the  entire  course  of  the  disease  enlarge- 
ment of  the  spleen  is  not  demonstrable  in  from  20  to  25  per  cent,  of 
the  cases. 

With  regard  especially  to  the  difficulties  attending  examination  of 
the  spleen  in  cases  of  typhoid  fever,  these  are  due  in  part  to  the  size  of 
the  organ  and  to  the  manner  in  which  it  reacts  at  different  times  to  the 
infectious  process,  and  in  part  to  topographic,  often  individual,  factors, 
or  to  antecedent  or  associated  lesions  in  adjacent  organs. 

Above  all,  it  should  be  mentioned  again  at  this  place  that  the 
typhoid  splenic  tumor  in  general  does  not  attain  any  considerable  degree 
1  Volkmann^s  Sammlung  klin.  Vortr. 


SYMPTOMS  AND  COMPLICATIONS.  181 

of  size.  In  the  middle  or  toward  the  end  of  the  first  week,  eveu  at 
the  beginning  of  the  second  week,  it  is  often  demonstrable  only  on  per- 
cussion or  is  palpable  by  those  expert  in  palpation  on  deep  inspiration 
just  below  the  costal  arch,  either  as  a  distinct  round  or  rather  sharp 
border,  or  as  a  sense  of  inspiratory  increase  in  resistance  in  the  region 
in  question.  Also,  at  the  height  of  the  disease,  with  which,  as  anatomic 
observation  has  shown,  most  marked  enlargement  of  the  spleen  coin- 
cides, it  is  possible  in  not  a  few  cases  to  detect  only  an  increase  in  the 
intensity  and  the  extent  of  the  dulness  without  trustworthy  findings  on 
palpation. 

In  the  minority  of  cases,  at  the  beginning  or  in  the  middle  of  the 
second  week,  at  times  even  somewhat  later,  the  splenic  tumor  apjoears 
distinctly  two  or  three  finger-breadths  below  the  costal  arch  even  during 
the  respiratory  mid-position.  The  anterior  inferior  border  of  the  spleen 
rarely  extends  much  further  downward ;  then  probably  only  when 
the  tumors  are  abnormally  large  or  when  the  spleen  has  an  unusual 
shape  (considerable  longitudinal  diameter — tongue-shaped),  or,  finally, 
if  the  spleen  is  displaced  downward  and  forward,  as  a  result  of  con- 
genital or  pathologic  conditions  or  due  to  relaxation  of  the  ligaments 
or  abnormal  adhesions  of  the  displaced  organ.  In  such  cases,  in  which 
the  splenic  tumor  can  be  palpated  throughout  a  considerable  extent, 
one  can  convince  himself  that  in  the  beginning  and  at  the  height  of 
the  disease  the  spleen  is  of  tense  elastic  consistency,  while  after  the 
height  of  the  disease  has  been  passed  it  becomes  distinctly  softer,  at 
times  to  such  a  degree  that  it  is  less  readily  demonstrable.  From  the 
differential  diagnostic  point  of  view  it  is  probably  true  that  old  malarial 
splenic  tumors  or  splenic  enlargements  due  to  leukemia  and  pseudo- 
leukemia appear  firmer  and  less  elastic,  while  enlargements  of  the  spleen 
induced  by  septic  processes  frequently  are  likely  to  be  softer  from  the 
beginning  and  throughout  their  entire  duration. 

Palpation  of  the  enlarged  spleen  in  the  course  of  typhoid  fever  is 
attended  with  little  or  no  tenderness.  At  times,  however,  on  palpation 
as  well  as  on  percussion,  complaint  is  made  of  a  certain  degree  of  pain. 
Still  more  rarely  patients  complain  spontaneously,  without  pressure  or 
movement,  of  dull  pain  beneath  the  left  costal  arch.  More  marked 
tenderness  on  palpation,  or  in  rotation,  on  flexion,  and  in  breathing,  is 
indicative  of  special  disease  of  the  spleen  or  its  immediate  vicinity-, 
including  first  of  all  perisplenitis,  which  may  even  be  associated  with 
pleuritis,   less  commonly  infarcts  and  abscesses. 

With  regard  to  special  anatomic,  topographic,  and  individual  influ- 
ences that  may   render   difficult  and  prevent  the  demonstration  of  a 


182  TYrilOID  FEVER. 

splenic  tumor,  accidt'iital  roiulitions  play  uo  small  role  in  this  connec- 
tion. Among  the  factors  that  must  frequently  hf  taken  into  consider- 
ation, mcteorism  especially  is  to  be  mentionoil.  As  meteorism  in  cases 
of  typhoid  fever  generally  involves  the  large  intestine,  and  especially 
the  neighborhood  of  the  greater  curvature  and  tlie  flexures  iu  most 
marked  degree,  Avhik'  tlie  distention  of  the  small  intestine  may  be  slight 
or  absent,  the  increased  difficulty  in  demonstrating  the  splenic  tumor 
need  by  no  means  always  be  dependent  upon  marked  overdistention  of 
the  entire  abdomen.  In  addition  to  the  gaseous  distention  of  the  intes- 
tine, abnormal  size  and  position  of  adjacent  portions  of  bowel,  especially 
the  frequent  formation  of  a  loop  of  colon,'  may  constitute  an  obstacle  to 
the  recognition  of  the  enlargement  of  the  sj)leen.  Not  rarely  there  are 
associated  with  these  conditions  the  displacements  of  the  sj)leen  already 
mentioned,  either  congenital  or  acquired,  occasionally  with  fixation  in 
abnormal  situations.  Exceptionally  also  the  organ  is  divided  into 
several  individual  parts,  a  spleen  with  so-called  supernumerary  spleens, 
thus  interfering  with  palpation.  That  technical  skill  is  also  a  factor  in 
the  examination  in  question  may  finally  be  worthy  of  mention. 

In  the  latter  connection  it  should  be  especially  pointed  out  that  if  the 
diagnosis  of  splenic  tumor  l)e  based  upon  the  results  of  percussion  alone,  the 
examination  should  be  made  frequently  throughout  a  certain  period  of  the 
disease,  and  it  should  always  yield  approximately  the  same  result.  Depend- 
ence should  by  no  means  be  placed  upon  the  results  of  a  single  percussion.^ 
It  is  noteworthy  that  to  the  skilled  clinician,  in  cases  in  which,  on  account 
of  meteorism  or  other  local  conditions,  increased  limits  of  the  area  of 
splenic  dulness  cannot  be  demonstrated,  special  intensity  of  the  dulness 
will  indicate  that  the  organ  is  abnormally  large.  The  greatest  significance, 
however,  should  be  attached  to  the  results  of  palpation  of  the  spleen, 
which  is  always  to  be  practised  bimanually  with  the  patient  in  the  right 
lateral  decubitus,  in  such  a  manner  that  the  left  hand  from  the  lumbar 
region  endeavors  to  push  the  posterior  abdominal  wall  and  the  organ  to  be 
palpated  against  the  right  hand,  applied  anteriorly  just  below  the  costal 
margin. 

Little  is  to  be  said  clinically  concerning  other  affections  of  the  spleen 
in  the  course  of  typhoid  fever.  Infarcts  and  profuse  hemorrhage  in  the 
splenic  tissue  almost  always  elude  diagnosis,  as  do  abscess  and  rupt- 
ure of  the  spleen,  which  occur  with  exceeding  rarity.  The  last-named 
conditions  are  indicated  almost  solely  by  symptoms  of  acute  peritonitis, 
'which  are  of  such  varied  etiologic  significance  that  those  complications 
will  at  most  be  thought  of  only  by  way  of  exclusion.      They  might 

^  "  Topographisch-klinische  Studien,"  Dfutsch.  Archiv,  Bd.  liii. 
^  See  also  von  Ziemssen,  "  Klinisehe  Beobachtun2;en  iiber  die  Milz,"  Munch,  med. 
Woch.,  1896,  No.  47,  a  communication  that  contains  a  number  of  valuable  technical 


SYMPTOMS  AND   COMl'LWATIONS.  183 

most  readily  be  suspected  if — as  has  now  and  again  been  observed — the 
onset  of  the  peritonitic  symptoms  were  immediately  preceded  by  sudden 
severe  pain  below  the  left  costal  arch. 

Even  on  post-mortem  examination  special  anatomic  lesions  of  the  splenic 
tissue  are  quite  rare.  Among  577  autopsies  at  Hamburg  and  Leipsic  I 
observed  infarcts  and  hemorrhage  in  25,  abscesses  in  4,  rupture  in  Z,  and 
extensive  recent  perisplenitis  in  16.  The  last-named  figure,  judging  from 
my  other  experiences,  is  rather  small.  The  statistics  of  Griessinger  bearing 
upon  anatomic  changes  in  the  spleen  quite  agree  with  my  own.  Among 
118  autopsies  he  noted  considerable  disease  of  the  spleen  in  9. 

Chang-es  in  the  Thyroid  Gland. — Although  little  has  been 
reported  anatomically  with  regard  to  the  condition  of  the  thyroid  gland 
during  the  ordinary  course  of  typhoid  fever,  even  less  has  been  observed 
clinically  in  this  connection.  Only  in  exceptional  cases  are  changes 
found  in  this  organ,  and  these  may  be  of  an  inflammatory  nature  of 
varying  intensity,  up  to  termination  in  abscess-formation,  Nevertheless, 
they  play  a  more  prominent  role  as  a  complication  of  typhoid  fever  than 
of  the  remaining  infectious  diseases. 

Walther,^  who  reported  several  cases  of  typhoid  thyroiditis  from  my 
clinic,  was  able  to  show  that  among  73  cases  of  acute  strumitis  and  thyroi- 
ditis collected  by  him,  40  were  traceable  to  typhoid  fever — an  interesting 
illustration  of  an  observation  previously  made. 

The  symptoms  of  typhoid  strumitis  consist  in  acute  painftd 
enlargement  of  the  thyroid  gland,  and  almost  always  of.  only  one-half 
or  of  a  still  smaller  portion.  Inflammation  of  the  entire  gland  appears 
to  be  extremely  rare  in  the  course  of  typhoid  fever. 

Just  as  we  were  able  to  demonstrate  with  regard  to  inflammation 
of  the  parotid  gland,  so  also  in  the  case  of  the  thyroid  gland,  the 
morbid  process  is  generally  observed  to  terminate  either  in  suppuration 
or  in  involution  of  the  inflammatory  process  without  the  development 
of  an  abscess.  The  disorder  appears  almost  always  to  pursue  a  favor- 
able course,  as  Liebermeister  has  shown,  and  I  have  been  able  to  deter- 
mine from  personal  experience.  Alarming  symptoms,  among  which 
dyspnea  from  compression  and  displacement  of  the  trachea  may  be 
mentioned,  are  among  the  rarest  exceptions.  Griessinger,  it  is  true, 
mentions  a  case  of  death  from  suffocation,  and  Forgue  lost  a  patient 
by  rupture  of  an  abscess  of  the  thyroid  gland  into  the  trachea. 

With  reference  to  the  etiology  of  typhoid  strumitis,  it  is  especially  to 
be  pointed  out  that  it  occurs  more  frequently  in  previously  h}^erplastic 
organs,  and  it  is  therefore  more  often  seen  in  regions  where  goiter 
prevails,  for  instance,  Switzerland. 

'  Inaug.  Diss.,  Leipsic,  1896. 


184  TYPHOID  FEVER. 

The  relatively  frequent  occurrence  of  thyroiditis  in  Switzerland  has  been 
demonstrated  by  the  statistics  of  Griessiuger  and  Liebernieister.  The  former 
observed  the  condition  4  times  in  ILS  autopsies,  the  latter  in  15  of  1700 
patients,  in  6  with  abscess-formation.  In  other  countries  thyroiditis  is 
far  less  common  in  accordance  with  the  greater  rarity  of  goiter.  Among 
349  autopsies  in  Hainburg  I  failed  to  observe  a  single  case.  Further,  during 
the  great  typhoid  epidemic  in  that  city  I  observed  the  condition  but  twice 
during  life.  In  Leipsic  also  it  is  a  great  rarity.  Topfer '  has  reported  3 
cases  of  abscess  of  the  thyroitl  gland  among  927  autopsies  at  Munich. 

It  is  interesting  to  note  that  Liehtbeim-Tavel,- Jeanselmo/'Schud- 
mark  and  A^luchos/'  and  several  others  have  demonstrated  the  bacillus 
of  Eberth  as  the  exciting  agent  of  the  inflammatory  process.  In 
other  instances  the  ordinary  pyogenic  micro-organisms,  streptococci  and 
staphylococci,  have  been  foimd.  Under  these  conditions  the  course 
Avas  often  more  unfavorable,  in  so  far  as  the  condition  was  a  part  mani- 
festation of  a  general  septicemia.  With  regard  to  the  period  when 
typhoid  strimiitis  occurs,  it  appears  to  coincide  especially  with  the 
beginning  of  convalescence  or  the  last  week  of  the  fever.  There  are 
but  few  reports  of  its  occurrence  at  an  earlier  period  in  the  course  of 
typhoid  fever. 

GENITaURINARY  ORGANS. 

The  Urinary  Apparatus. — From  the  practical  standpoint,  it 
appears  desirable  to  describe  now  the  changes  in  the  state  of  the  urine, 
in  so  far  as  they  relate  to  the  constitutional  disturbance  underlying 
the  attack  of  typhoid  fever,  especially  to  the  febrile  state,  and  to  follow 
this  wuth  a  description  of  the  conditions  that  are  attributable  to  direct, 
more  profound,  and  more  independent  disease  of  the  urinary  apparatus. 
During  the  febrile  stage  the  urine  resembles  in  many  respects  that 
excreted  in  other  acute  infectious  diseases.  Its  amount  is  generally 
diminished,  especially  during  the  first  three  weeks  of  the  disease — that 
is,  during  the  ordinary  duration  of  the  fever.  In  spite  of  abundant 
administration  of  fluid,  this  diminution  in  the  amount  of  urine  almost 
always  occurs,  naturally  with  variations  in  accordance  with  the  severity 
of  the  attack,  and  especially  in  accordance  with  the  intensity  and  the 
duration  of  the  fever. 

In  the  stage  of  steep  curves  the  amount  of  urine  is  generally  again 
increased,  returning  to  the  physiologic  even  as  early  as  the  beginning 
afebrile    period.       An    unusual    increase    in    the    secretion    of    urine 

^  "Die  Complicationen  des  Abdominaltyphus, "  Miinc.h.  med.  Woch.,  1892. 
^  Ueber  die  Aetioloffie  de?' Strumitis,  etc.,  Basle,  1892,  Sellmann. 
'  "  Contrib.  a  I'etude  des  thyroidites  infect.,"  Arch,  gen.,  July,  1893. 
*  Wien.  klin.  Woch.,  1900,  No.  29. 


SYMPTOMS  AND  COMPLICATIONS.  185 

during  the  progress  of  convalescence  is  by  no  means  a  rare  manifes- 
tation, so  that  the  amount  may  reach  10,000  c.cm.  and  more  in  twenty- 
four  hours.  The  urine  is  then  remarkably  light,  as  clear  as  water,  and 
of  exceedingly  low  specific  gravity — down  to  1002.  Rarely,  and  then 
especially  in  nervous  persons,  women  as  well  as  men,  this  polyuria  may 
be  apparent  as  early  as  the  later  portion  of  the  febrile  period. 

With  the  reduction  in  the  amount  of  urine  during  the  febrile  stage, 
the  remaining  manifestations  of  concentration  are  present :  abnormally 
dark  color,  generally  clear,  or  with  a  sediment,  which  then  consists 
principally  of  urates  and  uric  acid.  Not  rarely  the  dark  color  does  not 
correspond  entirely  with  the  specific  gravity.  The  color  may  be  inten- 
sified by  the  presence  in  the  urine  in  considerable  alnount  of  urinary 
pigments  other  than  the  ordinary  ones.  These  will  be  discussed  briefly 
later.  The  specific  gravity  is  almost  always  considerably  increased — 
up  to  1030  and  above;  rarely  it  declines  to  1020.  The  reaction  of  the 
urine  from  the  beginning  of  the  disease  and  at  the  height  of  the  fever  is 
invariably  strongly  acid,  unless  especial  conditions  are  present.  At  a 
later  stage  the  acidity  diminishes,  while  during  convalescence  the  urine 
frequently  presents  a  neutral  or  even  an  alkaline  reaction. 

Among  the  solid  constituents  of  the  urine,  the  urea  should  be  men- 
tioned first.  The  almost  invariable  and  marked  increase  in  the  amount 
of  urea  eliminated  in  twenty-four  hours  throughout  the  entire  febrile 
period  has  already  been  observed  by  earlier  writers — Neubauer  and 
Vogel,'  A.  Vogel,^  Prattler,^  Parkes,^  Murchison.  A  large  number  of 
personal  investigations  directed  to  this  point  have  yielded  the  same  result. 
I  have  not  at  all  rarely  observed  double  the  physiologic  average  amount 
of  urea,  and  now  and  again  even  more  than  this.  The  processes 
responsible  for  the  fever  in  cases  of  typhoid  fever  exert  distinctly  the 
most  important  influence  upon  the  increased  elimination  of  urea.  The 
view  that  the  elevation  of  temperature  alone — that  is,  the  increased 
heat  of  the  body-tissues — is  to  be  looked  upon  as  the  exciting  factor 
must  be  rejected  at  the  present  day.  Undoubtedly,  increased  elimina- 
tion of  urea  and  febrile  elevation  of  temperature  are  co-ordinated  mani- 
festations, dependent  upon  the  influence  of  the  toxins  upon  the  course 
of  metabolism. 

In  the  period  of  defervescence  a  reduction  in  the  elimination  of  urea 
begins  almost  invariably,  although  at  this  time  it  is  generally  above  the 
limits  observed  during  health.  During  the  period  of  convalescence 
the  physiologic  amount  eliminated  is  generally  again  attained.     In  a 

^  Anleitung  zur  Harnuntersuchung.  ^  Loc.  c'lt. 

3  Loc.  cit.  *  On  the  Urine,  1860. 


18G  TYPHOID  FEVER. 

mmiber  of  instances  I  have  observed  even  during  convalescenee — even 
where  the  mode  of  nonrishing  the  patient  in  such  cases  did  not  differ 
from  that  in  other  cases  of  typhoid  fever — a  considerable,  long-main- 
tained increase  in  the  elimination  of  urea.  With  this  was  constantly 
associated  progressive  reduction  in  the  body-weight,  a  conditi(m  that 
appears  to  render  such  cases  worthy  of  further  investigation.  It  has 
been  stated  l)y  some  writers  that  even  at  the  height  of  the  attack  in 
severe  so-called  adynamic  cases,  sudden  reduction  in  the  amount  of 
urea  may  be  observed,  and  that  this  manifestation  is  calculated  to  render 
the  prognosis  much  more  grave.  I  have  personally  not  as  yet  made 
such  an  observation. 

Like  the  urea,  the  lu'ic  acid  is  also  almost  unexceptional ly  increased 
in  the  febrile  stage,  and  at  times  quite  considerably.  The  elimination 
of  uric  acid  is  also  diminished  again  with  the  commencement  of  con- 
valescence, and  returns  to  the  normal  during  the  period  of  recovery. 
The  reports  by  Frerichs  and  Stiidler  with  regard  to  the  presence  of 
leucin  and  tyrosin  are  familiar  and  often  cited ;  Griessinger  also  con- 
siders those  substances  as  almost  constantly  present. 

The  chlorids,  as  in  many  other  acute  infectious  diseases,  are  always 
greatly  diminished  during  the  febrile  stage,  to  increase  again  consider- 
ably with  the  subsidence  of  the  disease.  The  opinion  of  Jid.  Vogel, 
that  the  diminution  in  chlorids  is  dependent  solely  upon  the  lessened 
amount  of  sodium  chlorid  ingested  with  the  febrile  diet,  is  no  longer 
tenable.  This  phenomenon  occurs  now  as  formerly,  although  it  has 
become  customary  in  cases  of  typhoid  fever  to  administer  concentrated 
nourishment  containing  an  abundance  of  sodium  chlorid  instead  of  a 
diet  of  watery  soups.  The  more  recent  hypotheses  with  reference  to 
the  reduction  in  chlorids,  however,  also  appear  vulnerable,  so  that,  as  a 
matter  of  fact,  it  would  appear  worth  while  to  undertake  a  new  study 
of  the  question. 

The  appearance  of  albumin  in  the  urine  in  cases  of  typhoid  fever  is 
of  especial  importance.  The  substances  found  under  such  circum- 
stances are  known  to  be  serum-albumin  and  serum-globulin.  Less 
commonly,  and  only  under  certain  definite  conditions,  does  peptone 
appear  in  the  urine,  as  Gerhardt  was  the  first  to  point  out.  We  shall 
first  take  up  the  consideration  of  the  elimination  of  albumin  that 
occurs  without  profound  disease  of  the  kidneys,  and  is  generally  desig- 
nated as  febrile  albuminuria.  We  shall  return  at  a  sei)arate  place  to  a 
consideration  of  the  albuminuria  due  to  actual  nephritis. 

Febrile  albuminuria  is  one  of  the  more  common  manifestations. 
According  to  my  experience,  it  can  be  demonstrated  in  from  15  to  20 


SYMPTOMS  AND   COMPLICATIONS  137 

per  cent,  of  cases  of  typhoid  fever.  I  have  reached  this  conclusion 
from  the  study  of  a  large  number  of  cases,  including,  naturally,  mild 
as  well  as  marked  cases.  In  a  number  of  extensive  epidemics  l'  have 
observed  the  proportion  to  be  lower;  for  instance,  in  that  at  Hamburg 
in  1886-1887  only  10.7  per  cent,  of  the  cases  exhibited  febrile  albu- 


minuria. 


The  latter  figures  are  approximated  also  by  my  Leipsic  statistics,  in  which 
the  proportion  was  11.3  per  cent.  On  the  other  hand,  the  statement  of 
Ijubler,  that  albummuna  is  constant  during  typhoid  fever,  is  difficult  of 
explanation  Other  observers  name  higher  figures  than  I  do,  as,  for  instance 
Murchison,  who  observed  albuminuria  in  93  of  282  cases— 32.26  per  cent' 
ihis  isassuredly  not  the  rule  ;  possibly  it  may  be  explicable  by  the  fact  that 
Murchison  s  statistics  are  based  upon  a  collection  of  smaller  individual  data 
(personal  observation  and  that  of  six  other  writers),  and  that  severe  cases 
especially  were  taken  into  consideration.  It  is  true  also  that  Weil '  and 
C^riessinger  give  high  comparative  percentages.  The  latter  believes  that 
tebriJe  albuminuria  occurred  in  one-third  of  his  cases. 

Albumin  was  present  at  some  stage  of  the  disease  in  616  of  829  cases 
(74  per  cent.)  treated  at  the  Johns  Hopkins  Hospital  (Osier*)  This 
includes  the  cases  in  which  the  albumin  was  considerable  in  amount  as  well 
as  those  in  which  the  faintest  possible  trace  of  albumin  was  present. 

The  amount  of  albumin  eliminated  varies  from  traces  to  moderate 
amounts.  The  presence  of  a  large  amount  should  always  lead  to  more 
careful  examination  for  the  presence  of  profound  disease  of  the  kidneys, 
which  can  almost  always  be  demonstrated  under  such  conditions.  It 
can  be  stated  definitely  that  only  the  more  severe  and  the  severest 
cases  exhibit  albiuninuria.  The  condition  is  therefore  one  that  makes 
the  prognosis  distinctly  more  grave,  and  the  more  so  the  earlier  it 
appears,  the  longer  it  persists,  and  the  greater  the  amount  of  albumin 
eliminated.  Of  393  cases  of  febrile  albuminuria  that  I  have  collected 
death  occurred  in  107—27.2  per  cent.— a  mortality  fully  three  times 
the  normal. 

As  the  period  for  the  beginning  of  albuminuria  I  would  designate 
the  end  of  the  first  and  the  entire  second  week,  in  contradistinction 
from  other  writers  (Murchison  and  Finger),  who  have  never  observed 
It  before  the  sixteenth  day,  and  most  frequently  between  this  time  and 
the  twenty-fifth  day  of  the  disease ;  its  advent,  however,  is  also  quite 
frequent  to  the  end  of  the  third  week,  and  upon  this  point  I  am  in 
agreement  with  Weil.  Its  occurrence  becomes  less  frequent  after  the 
third  week ;  it  has,  however,  come  under  my  observation  even  quite 
late,  up  to  the  forty-eighth  day  of  the  disease.     I  consider  late  appear- 

^  Diet,  des  sci.  med.,  Art.  "  Albuminurie."  2  ^oc.  cit.,  p.  488. 

2  Zur  Pathologic  und  Therapie  des  Ahdominaltyphus,  1883. 
*  Johns  Hopkins  Hosp.  Rep.^  vol.  viii.,  p.  467. 


188  TYPHOID  FEVER. 

auee  of  albuminuria  especially  unfavorable  from  the  prognostic  point  of 
view.  I  have  observed  it  to  be  followed  by  death  in  an  unusually  large 
number  of  cases.  In  isolated  cases  I  have  observed  albumin  to  appear 
in  the  urine  during  the  first  week,  to  disappear  in  the  course  of  a  few 
days,  and  then  to  reappear  in  varying  amount  and  for  a  varying  period. 
Striking  as  this  fact  is  in  itself,  I  have  been  unable  to  establish  any 
relation  between  it  and  other  deviations  in  course  and  termination.  The 
observation  that  the  albuminuria  is  likely  to  be  increased  or  to  reappear 
during  relapses  and  recrudescences  has  been  emphasized  frequently. 

The  duration  of  febrile  albuminuria  in  the  individual  case  appears  to 
correspond  approximately  Avitli  its  intensity.  In  three-fourths  of  all 
cases  it  persists,  in  my  experience,  less  than  tweh'c  days.  A  duration 
up  to  three  weeks,  exceptionally  also  longer,  is  not  at  all  rare.  Of  92 
cases  of  febrile  albuminuria  that  I  have  analyzed,  I  foimd  the  duration 
to  be  from  one  to  three  days  in  5  cases ;  from  four  to  six  days  in  25  ; 
from  seven  to  nine  days  in  20  ;  from  ten  to  tsvelve  days  in  12;  from 
thirteen  to  twenty -one  days  in  25  ;  from  twenty-two  to  twenty-seven 
days  in  5. 

ISIicroscopic  examination  of  the  urinary  sediment  discloses  in  cases 
of  pure  febrile  albuminuria,  in  addition  to  crystalline  structures,  espe- 
cially uric  acid  and  urates,  isolated  white  blood-corpuscles  and  epithelial 
cells  from  the  urinary  passages,  and  generally  a  few  hyaline,  otherwise 
unchanged,  tube-casts.  In  the  presence  of  slight  albuminuria  their 
number  is  generally  so  small  that  they  can  be  found  only  in  the  sedi- 
ment obtained  with  the  aid  of  the  centrifuge.  Osier  ^  states  that  tube- 
casts  were  present  in  391  of  the  829  cases — 47  per  cent.  ;  or,  in  other 
words,  63  per  cent,  of  the  cases  sho^Aong  albuminuria  also  showed 
the  presence  of  tube-casts.  Tube-casts  of  other  kinds,  and  especially 
increase  in  the  nmnber  of  leukocytes,  with  evidences  of  increased  des- 
quamation on  the  part  of  the  kidneys,  are  indicative  of  more  profound 
lesions.  In  rare  cases  the  albuminuria  of  typhoid  fever  may  persist 
even  throughout  convalescence  without  having  been  referable  in  the 
course  of  the  disease  to  nephritis,  and  it  may  give  rise  to  a  long-con- 
tinued peculiar  form  of  albuminuria,  at  times  never  wholly  disappear- 
ing, which  yet  awaits  thorough  anatomic  investigation. 

I  have  observed  such  cases  on  several  occasions,  but  have  hitherto  had 
no  opportunity  for  anatomic  investigation,  so  that  I  am  without  knowledge 
as  to  their  nature.  They  are  almost  always  characterized  by  the  presence 
of  a  normal  amount  of  clear  urine  of  normal  character  and  of  normal 
specific  gravity,  with  a  small  amount  of  morphologic  elements  :  scarcely  any 
epithelial  cells  from  the  uriniferous  tubules,  a  small  number  of  tube-casts 

^  Loc.  cit. 


\ 


SYMPTOMS  AND   COMPLICATIONS.  189 

exclusively  of  the  hyaline  variety,  never  any  red  blood-cells,  and  at  most  a 
few  white  corpuscles.  Cardiac  hypertrophy  and  edema  apparently  do  not 
occur,  and  I  have  likewise  failed  to  observe  uremic  manifestations.  In  some 
instances  I  have  observed  such  albuminuria  to  persist,  in  a  characteristic 
manner,  for  ten  or  twelve  years  after  the  attack  of  typhoid  fev^r  (treated  by 
me),  apparently  without  any  further  injurious  effect  upon  the  healthy-looking, 
functionally  capable  individual,  who,  on  account  of  the  results  of  examination 
of  the  urine,  may  become  temporarily  depressed  or  even  permanently  hypo- 
chondriacal— the  only  manifestation  suggestive  of  the  existence  of  disease. 
In  isolated  cases  I  have  noted  complete  disappearance  of  this  albuminuria, 
even  after  the  lapse  of  years,  with  the  persistent  peculiarity,  it  is  true,  that 
slight  transitory  turbidity  of  the  urine  developed  on  the  application  of  tests 
for  albumin  after  active  bodily  exercise  or  after  the  ingestion  of  strong 
alcoholic  beverages.  I  have  observed  a  similar  form  of  chronic  albuminuria, 
the  anatomic  basis  for  which  has  not  been  clearly  determined,  following 
other  acute  infectious  diseases  also,  especially  dysentery,  cholera  nostras, 
and  necrotic  angina. 

In  addition  to  the  more  common  changes  in  the  state  of  the  urine 
mentioned,  a  number  of  less  common  substances  and  reactions  are 
worthy  of  mention.  The  increase  of  urobilin  that  occurs  in  the  urine, 
and  is  at  times  so  marked  that  the  condition  is  appropriately  designated 
urobilinuria  (Tissier  ^),  is  interesting.  Tissier  and  others  are  inclined  to 
associate  the  manifestation  with  profound  (typhoid)  alterations  in  the 
liver  and  the  biliary  passages.  According  to  Tissier,  the  most  marked 
urobilinuria  can  be  found  only  in  severe  cases,  while  that  of  moderate 
grade  will  be  present  in  mild,  but  protracted,  cases.  I  have  no  personal 
experience  in  this  connection. 

The  appearance  of  moderate,  and  even  of  considerable,  amounts  of 
indican  in  the  urine  is  quite  frequent,  and  is  an  indication  of  derangement 
in  proteid  digestion  and  absorption.  I  am,  however,  by  no  means  of 
the  opinion  that  any  direct  relation  exists  between  the  amount  and 
duration  of  indican-elimination  and  the  severity  of  the  attack  of  typhoid 
fever ;  and  I  am  unable  to  attribute  to  it  either  diagnostic  or  special 
prognostic  significance.  I  have  often  observed  a  more  pronounced  indi- 
can-reaction  in  mild  cases  of  typhoid  fever,  especially  when  attended  with 
profuse  diarrhea,  or,  conversely,  with  obstinate  constipation,  than  in 
severe  cases.  It  need  scarcely  be  mentioned,  in  view  of  what  is  known 
in  general  in  this  connection,  that  with  the  onset  of  general  peritonitis 
and  also  of  circumscribed  peritonitis,  particularly  in  connection  with 
typhoid  perityphlitis,  especially  marked  elimination  of  indican  takes 
place. 

I  have  encountered  true  hemoglobinuria  associated  with  hemoglob- 
inemia  in  but  2  cases  of  typhoid  fever.     In  one  of  these  it  occurred 

1  These,  Paris,  1890. 


190  TYPHOID  FEVER. 

iu  the  middle  of  the  seeoiul,  and  in  the  other  at  the  beginning  of  the 
third,  week.  Both  cases  terminated  fatally  with  .symptoms  of  most 
profound  intoxication.  Klemperer '  has  recently  reported  a  case  of 
hemoglobinuria  after  recovery  from  a  severe  attack  of  typhoid  fever. 

Roque  and  Weill "  were  the  first  to  call  attention  to  the  presence 
of  intensely  toxic,  probably  specific  substances  in  the  wy'ww  of  patients 
suffering  from  typhoid  fever.  Le})ine  and  (luerin  have  R'jjorted  most 
remarkable  observations  of  a  similar  character.  In  the  light  of  existing 
knowledge  with  regard  to  the  presence  of  toxins  and  antitoxins  in  the 
circulating  blood  iu  cases  of  typhoid  fever,  these  observations  should 
stimulate  further  active  investigation. 

It  is  finally  necessary  at  this  place  to  refer  to  the  diazo-reaction  of 
Ehrlich  with  the  urine  in  cases  of  typhoid  fever,  the  principles  of  which 
and  the  method  of  eliciting  it  may  be  presumed  to  be  familiar.  Doubtless, 
this  important  reaction  can  always  be  obtained  at  the  height  of  an  attack 
of  typhoid  fever ;  it  is  permanently  absent  only  in  the  milder  cases.  It 
is  also  undoubted  that  in  severe  cases,  when  improvement  begins  to  take 
place,  the  reaction  not  rarely  disappears,  so  that  from  this  sign  favor- 
able conclusions  may  be  drawn  at  a  time  when  other  symptoms  are  not 
indicative  of  improvement  or  are  uncertain  in  this  regard.  It  is  note- 
worthy, also,  that  in  relapses  from  typhoid  fever  the  diazo-reaction,  if 
it  had  already  disappeared,  generally  returns,  while  it  does  not  reajjpear 
when  fever  occurs  during  convalescence  from  typhoid  fever  as  the  result 
of  organic  disturbances  due  to  other  causes.  In  all  these  connections  a 
certain  degree  of  diagnostic  and  prognostic  value  is  distinctly  to  be 
attached  to  the  reaction,  although  it  is  not  absolute.  Thus,  rarely,  it  is 
true,  severe  and  even  also  anatomically  demonstrable  cases  of  typhoid 
fever  have  been  observed  in  which  the  reaction  was  continuously 
absent  owing  to  undeterminable  causes.  In  addition,  the  reaction  occurs 
with  especial  frequency,  almost  invariably,  in  other  febrile  diseases,  and 
particularly  such  as  ofl'er  difficulty  in  differential  diagnosis,  especially 
miliary  tuberculosis  and  florid  forms  of  pulmonar}^  tuberculosis,  typhus 
fever,  certain  varieties  of  profound  pneumonia,  malaria,  and,  finally, 
acute  exanthemata,  particularly  measles. 

The  terra  typhoid  bacilluria  or  bacteriuria  has  been  applied  to  the 
condition  in  which  typhoid-bacilli  are  found  in  the  urine.  This  occurs 
in  from  20  to  30  per  cent,  of  all  cases.  The  bacilli  may  be  present  in 
small  numbers,  or  they  may  occur  in  enormous  numbers,  so  as  to  render 
the  urine  distinctly  turbid.  Horton-vSmith  has  laid  special  stress  on 
the  ])eculiar  shimmer  which  is   seen  when  a  test-tube  filled  with  such 

'  Charite  Annnlen,  20.  Jahrg.,  1895.  =*  Rev.  de  Med.,  1891. 


SYMPTOMS  AND    COMFLICATIONS.  191 

urine  is  held  up  to  the  h'ght  and  gently  shaken.  In  this  way  the  con- 
dition can  often  be  predicted  without  cultures  and  without  microscopic 
examination.  Usually,  the  bacilli  do  not  appear  in  the  urine  before  the 
fifteenth  day,  and  they  may  persist  for  a  variaVjle  length  of  time — 
even  for  months  or  years  after  convalescence  (seven  years  in  the  case 
reported  by  Young  ^).  The  recognition  of  this  condition  is  even  of 
more  importance  from  the  hygienic  standpoint  than  from  the  diagnostic. 
A  patient  voiding  such  urine  is  a  source  of  constant  danger  to  all  those 
about  him. 

Associated  with  the  bacilluria  is  frequently  a  moderate  or  even  an 
extreme  grade  of  pyuria.  It  is  not  uncommon  for  the  urine  of  typhoid 
patients,  especially  if  albuminuria  be  present,  to  contain  a  few  pus-cells. 
If,  however,  the  pus  is  considerable  in  amount,  one  should  always  sus- 
pect the  presence  of  a  typhoidal  bacilluria.  If,  in  addition  to  the  pus, 
the  patient  complains  of  slight  pain  in  passing  the  urine  and  slight 
frequency  of  micturition,  it  is  probable  that  a  mild  grade  of  cystitis 
exists,  which  may  pass  into  a  more  severe  form  or  even  become  chronic. 
Thus,  no  hard-and-fast  line  can  be  drawn  between  bacteriuria  and 
cystitis.  Apparently,  however,  mere  presence  of  the  bacteria  in  the 
bladder  is  not  sufficient  to  cause  cystitis.  Horton-Smith  concludes 
that  "  the  bacilluria  is  due  to  infection  of  the  urine  by  a  stray  typhoid- 
bacillus,  excreted  by  the  kidneys  from  the  blood,  and  its  immediate 
multiplication  in  the  bladder-urine.  If,  in  addition,  the  bladder-walls 
have  been  in  any  way  damaged,  then  true  typhoidal  cystitis  follows." 

Nephritis. — Emphasis  has  already  been  placed  upon  the  fact  that 
febrile  albuminuria  cannot  be  sharply  diiferentiated  from  the  nephritis 
not  rarely  attending  typhoid  fever,  and,  as  it  appears,  etiologically 
related  to  this  disease.  Each  may  undoubtedly  pass  over  into  the  other, 
and  they  are  attributable  in  part  to  the  same  cause,  namely,  the  action 
of  toxins.  The  nephritis  generally  occurs  in  the  form  of  acute  paren- 
chymatous inflammation,  in  part  hemorrhagic,  in  part  non-hemorrhagic. 
The  nephritis  generally  occurs  at  the  height  of  the  disease,  before  the 
end  of  the  third  week ;  and  it  is  much  less  common  at  a  later  period. 

1  have,  however,  observed  it  appear  on  the  thirtieth  day,  and  in  one 
instance  even  during  convalescence.  Cases  of  the  latter  variety  are 
then  likely  to  be  prolonged  for  some  time.  Of  32  cases,  I  noted  the 
appearance  of  nephritis  before  the  end  of  the  third  week  in  18.     In 

2  cases  the  onset  of  the  complication  was  placed  respectively  at  the 
beginning  and  the  middle  of  the  first  week. 

Age  and  sex  exhibit  little  that  is  peculiar,  although  it  appears  to  me 

^  Johns  Hopkins  Hosp.  Rep.,  vol.  viii. 


192  TYPHOID  FEVER. 

that  men  are  attacked  somewhat  more  frequently  than  women,  and  in 
this  eoinieetion  it  is  probable  that  the  mode  of  life,  especially  alcohol- 
ism, plays  a  jiart.  Of  84  eases  of  nephritis  in  adults  (Leipsic  and  Ham- 
burg statistics),  54  occurred  in  males.  The  proportion  is  more  striking 
in  the  Leipsic  statistics  alone,  where  of  53  cases  of  nephritis,  41  were  in 
males.  In  children,  particularly  during  the  early  years  of  life,  I  have 
observed  nephritis  in  but  2  cases.  Among  adults  no  special  predis- 
position Avith  regard  to  age  appears  to  exist.  During  this  period  the 
frequency  of  nephritis  is  about  the  same  as  that  of  the  predisposition  of 
various  ages  to  typhoid  fever  generally.  Of  25  cases  of  nephritis,  3 
were  imder  sixteen  years  of  age ;  1 1  between  sixteen  and  twenty-five 
years  inclusive ;  8  between  t^venty-six  and  thirty-five  years ;  1  between 
thirty-six  and  forty-five  years ;  1  between  forty-six  and  fifty-five  years ; 
1  above  fifty-five  years. 

Numerous  general  statements  have  been  made  with  regard  to  the 
macroscopic  anatomy  of  typhoid  nephritis,  but  relatively  few  with 
regard  to  the  finer  alterations.  Besides  findings  similar  to  those  attend- 
ing acute  inflammatory  lesions  of  the  kidneys,  which  are  occasionally 
obsei'ved  in  association  with  other  infectious  diseases,  numerous  ob- 
servers have  reported  cases  pursuing  an  extremely  pernicious  course  in 
w^hich  microscopic  examination  is  said  not  to  have  disclosed  any  essen- 
tial histologic  alterations  whatever.  These  observations,  it  is  true,  were 
made  at  an  earlier  period,  and,  if  repeated  with  the  aid  of  modern 
methods,  they  might  perhaps  yield  more  satisfactory  results.  An 
attempt  has  been  made  to  separate  from  the  ordinary  cases  of  typhoid 
nephritis  certain  varieties  that  are  characterized  by  the  appearance 
especially  early  and  in  intense  degree  of  the  renal  manifestations,  and 
by  the  unusual  duration  of  the  same.  These  may,  in  fact,  so  thor- 
oughly dominate  the  entire  clinical  picture  that  some  French  writers 
have  devised  the  special  designation  nephrotyphoid  for  such  cases. 

Among  the  first  of  the  cases  of  this  character  in  the  literature  are  2  by 
Immermann/  in  which  nephritis,  occurring  at  the  height  of  the  disease  and 
accompanied  by  uremic  manifestations,  led  to  a  fatal  termination.  The  first 
to  describe  the  condition  as  a  special  disorder  was  Gubler,'^  and  he  was  fol- 
lowed by  Legroux  and  Hanot'  with  statistical  reports,  and  Robin,  a  pupil  of 
Gnbler's,  who  completed  the  description  of  his  teacher  and  proposed  the 
designation  "nephrotyphoid."  Amat  *  then  elaborated  the  schematic  limi- 
tations and  description  of  this  form  of  disease  to  a  refined  degree,  and  even 
believed  that  it  presented  special  anatomic  conditions,  considerable  enlarge- 

^  Jahresberieht  der  Medicin.     Abtheilung  des  BiirgerHpitals  zu  Basel,  1872. 
^  Loc.  cit. 

^  "  Observat.  d'albuminurie  dans  la  fievre  typh.,"  Arch.  gen.  deyned.,  1876. 
*  "  Sur  la  tievre  tj'ph.  en  forme  renale, "  These,  Paris,  1878. 


SYMPTOMS  AND   (JOMI'LKJATIOhS.  193 

ment  of  the  kicluey,  with  evidences  of  acute  interstitial  inflammation,  espe- 
cially of  the  cortical  structure.  According  to  Aniat,  the  urine  is  invariably 
characterized  by  its  intensely  bloody  color  and  the  i)resence  of  large  amounts 
of  albumin,  with  numerous  tube-casts,  blood-corpuscles,  epithelial  cells  and 
their  degeneration-products.  In  addition  there  is  said  to  be  from  the  outset 
remarkably  high  fever,  with  early,  profound  stupor,  but  with  an  absence  of 
the  usual  abdominal  symptoms  of  typhoid  fever. 

Kussmaul  ^  was  one  of  the  first  in  Germany  to  direct  attention  to  the 
Gubler-Robin  type  of  disease,  but  with  his  customary  penetration  attributed  to 
it  its  proper  degree  of  importance.  The  3  cases  upon  which  his  paper  was 
based  exhibited  by  no  means  complete  agreement,  and  therefore  cannot  be 
used  in  support  of  the  doctrine  of  a  special  form  of  nephrotyphoid  in  the 
sense  of  the  French  clinicians. 

Personally,  I  am  of  the  opinion  that  acute  parenchymatous  nephritis 
appearing  early  and  pursuing  a  severe  course  during  an  attack  of 
typhoid  fever  should  be  considered  as  a  particularly  serious  occurrence. 
There  is,  however,  no  reason  for  the  recognition  of  a  distinct  variety 
of  nephrotyphoid,  or  for  the  separation  of  this  from  other,  milder  forms 
of  nephritis,  of  shorter  duration,  occurring  in  the  course  of  or  toward 
the  end  of  the  disease.  The  diiferences  and  the  contrasts  are  here  not 
so  sharp  as  was  theoretically  believed.  On  the  contrary,  if  a  series  of 
distinctive  cases  are  compared,  a  gradual  transition  will  be  noted.  The 
urine  contains  a  large  amount  of  albumin,  with  numerous  hyaline,  gran- 
ular, and  epithelial  tube-casts  and  a  considerable  amount  of  blood,  and 
the  disease  in  other  respects  pursues  the  typical  course  of  typhoid,  with 
marked  abdominal  symptoms ;  and  these  facts  must  be  emphasized  as 
opposed  to  the  assumption  of  a  separate  condition  exclusive  of  both 
typhoid  and  nephritis.  Excessive  stupor  or  other  unusual  nervous 
manifestations  are,  further,  by  no  means  always  associated  with  such 
profound  alteration  in  the  condition  of  the  urine.  There  is  even  no 
constant  association   of  high  fever  with  profound  nephritis. 

With  regard  to  the  frequency  of  true  typhoid  nephritis,  if  it  be 
differentiated  as  sharply  as  possible  from  febrile  albuminuria,  it  will  be 
found,  as  has  been  said,  to  be  not  at  all  large.  In  my  experience  the 
condition  occurs  in  scarcely  1  per  cent,  of  the  cases.  The  prognosis  of 
typhoid  nephritis  is  grave,  and  on  this  point  it  must  be  admitted  that 
the  French  investigators  are  correct,  but  this  is  not  so  because  the 
organism  is  especially  affected  by  the  severity  of  the  disease  of  the  kid- 
neys, but  rather  because  the  occurrence  of  severe,  especially  hemorrhagic, 
nephritis  is  one  of  the  local  symptoms  of  unusually  profound  general 
intoxication.  Almost  half  of  all  patients  with  typhoid  nephritis  die.  In 
this  respect  my  experience  at  Hamburg,  where  I  observed  a  mortality 

^  Homburger,  Berlin,  klin.  Woch.,  1881,  Nos.  20,  21,  and  22  ( Mittheilungen  aus 
der  Kussmaul 'schen  Klinik). 
13 


194  TYPHOID  FEVER. 

of  50  per  cent.,  differs  little  from  that  at  Leipsic,  \vith  44.4  per  cent. 
Of  229  cases  of  typhoid  fever  at  the  Johns  Hopkins  Hospital/  there 
Mere  definite  evidences  of  an  acute  nephritis  in  21.  Of  these  21,  7  died 
— 33.3  per  cent.  Death  occurs  either — and  this  is  the  more  common — 
amid  symptoms  of  most  profound  general  intoxication,  or  with  the  super- 
vention of  various  complications.  In  5  of  the  7  cases  above  mentioned, 
death  was  due  to  perforation.  In  my  experience  actual  uremia  develops 
less  commonly.  I  have  in  but  1  instance  t)bserved  death  to  occur  from 
uremia.  This  was  in  a  young  man,  in  the  first  half  of  the  second  week  of 
an  attack  of  typhoid  fever,  who  developed  convulsions  and  coma,  after 
symptoms  of  hemorrhagic  nephritis  had  existed  for  a  few  days  only.  In 
addition  to  the  cases  of  Immermanu  that  belong  in  this  category,  reference 
should  be  made  to  the  report  of  Murchison.  A  case  of  Robert  and 
Gaucher,'-  terminating  in  recovery,  appears  not  to  belong  in  this  group. 

The  duration  of  cases  of  typhoid  nephritis  in  which  complete 
recovery  takes  place  is  variable.  Most  frequently  it  appears  to  be  from 
one  to  two  weeks.  I  have,  however,  also  observed'  protracted  cases 
that  lasted  as  long  as  nine  weeks.  Incomplete  recovery  with  transfor- 
mation of  acute  nephritis  into  the  chronic  variety  appears  to  be  a  rare 
exception,  in  contrast  with  some  other  infectious  diseases  in  which  this 
is  well  known  to  be  not  uncommon.  In  a  large  experience  I  have  per- 
sonally observed  but  1  case  that  could  be  included  in  this  category.  No 
such  case  has  occurred  at  the  Johns  Hopkins  Hospital,  and  Osier  ^  has 
never  seen  such  a  case. 

Of  other  diseases  of  the  kidney  in  the  course  of  typhoid  fever, 
virtually  nothing  is  as  yet  known  clinically.  The  multiple  and  the 
diffuse  lymphomata  of  Wagner,''  the  exceedingly  rare  infarcts  and  multi- 
ple abscesses,^  are  attended  in  general  with  no  symptoms,  or  at  most 
with  the  appearance  of  albiuninuria.  Even  noteworthy  hematuria,  in 
consequence  of  infarction,  may  be  considered  as  exceedingly  rare. 

GENERATIVE    ORGANS. 
Male  Genitalia. — Diseases  of  the  male  genitalia  in  the  course  of 
typhoid  fever  are  not  so  frequent  and  important  as  are  those  of  the 
female.     As    in    other    infectious    diseases,   especially  variola,   inflam- 
matory   affections    of    the    testicle    occur    in  the    course    of    typhoid 

1  Hewetson,  Johns  Hopkins  Hosp.  Re]).,  vol.  iv.  '^  Rev.  de  Med.,  1881. 

'  Ibid.,  vol.  viii. 

*  Arch.  d.  Heil.,  Bd.  ii.,  and  "  Nierenkrankheiten,"  von  Zieynssen's  Handbuch, 
2.  Aufl. 

*  See  the  classic  case  of  von  Kecklinghausen,  Verhandl.  d.  phys.-med.  Gesellsch. 
z.  Wurzburg,  1871. 


I 


SYMPTOMS  AND   COMPLICATIONS.  195 

fever.  Not  much  can  be  said  in  general  with  regard  to  their  fre- 
quency, as  they  have  not  as  yet  been  so  thoroughly  and  admirably 
studied  as  has  the  orchitis  of  variola  (Chiari).  Typhoid  orchitis  appears 
to  occur  rarely  at  the  beginning  of  the  disease,  while  it  is  almost  always 
a  manifestation  of  the  last  part  of  the  febrile  stage  or  the  first  part  of 
convalescence.  It  begins  with  chilliness,  or  even,  as  I  have  observed 
in  1  case,  with  a  chill.  In  any  event,  it  is  almost  always  attended  with 
marked  elevation  of  temperature.  The  testicle  and  the  epididymis  are, 
under  such  circumstances,  often  indurated  and  swollen,  and  the  skin 
of  the  scrotum  is  reddened  and  occasionally  edematous.  The  testicle 
is  usucilly  aifected  first,  and  often  alone ;  less  commonly  the  epididymis 
is  aifected  first  or  alone  (Eshner).  The  pains,  which  radiate  in  tlie 
course  of  the  spermatic  cord  to  the  abdominal  cavity,  are  generally 
severe,  so  that  they  deprive  irritable  individuals  of  sleep  and  rest. 
Termination  in  recovery  is  the  rule.  This  was  completed  in  from  ten 
to  fourteen  days  in  all  the  cases  under  my  observation.  I  have 
hitherto  never  observed  termination  in  suppuration,  which  appears,  on 
the  whole,  to  be  exceedingly  rare.  Quite  exceptionally  atrophy  of 
the  testicle  develops.  In  a  case  mider  my  observation  sterility  in  the 
male,  dependent  upon  azoospermia,  was  with  probability  attributed  to 
a  previous  bilateral  typhoid  orchitis  from  which  recovery  had  taken  place. 

I  have  personally  observed  typhoid  orchitis  in  6  cases,  and  in  all  it 
was  unilateral.  In  4  instances  the  testicle  alone  was  inflamed,  and  in  2 
together  with  the  epididymis.  The  afiection  appears  not  to  occur  in  children. 
It  develops  chiefly  in  young  men.  Five  of  my  patients  were  under  thirty, 
and  but  one  forty-five  years  old.  An  interesting  study  upon  this  subject  has 
been  made  by  Ollivier/  who  analyzed  3  cases  of  his  own  and  a  consid- 
erable number  from  other  sources.  There  may  be  mentioned,  besides,  among 
French  observers,  Cervelle  '^  and  Sorel,^  and  among  German  observers  espe- 
cially Liebermeister,*  who  observed  orchitis  in  3  cases  among  200  of  typhoid 
fever. 

A  late  review  of  the  cases  of  typhoid  orchitis  has  been  made  by  Eshner,^ 
who  collected  43  cases  from  the  literature,  besides  reporting  1  of  his  own. 
Ten  of  these  are  mentioned  as  having  gone  on  to  suppuration,  and  from  the 
pus  of  5  of  these  cases  the  typhoid-bacillus  was  cultivated.  From  a  study 
of  these  cases  he  concludes  that  in  most  instances  the  condition  is  dependent 
upon  infection  through  the  blood  with  typhoid-bacilli,  although  the  pos- 
sibility of  infection  by  continuity  through  the  urethra  with  typhoid-bacilli 
or  other  micro-organisms  cannot  be  excluded. 

The  occurrence  of  emissions  with  abnormal  frequency  in  convales- 
cents from  typhoid  fever  is  worthy  of  mention,  because  at  times  of 

'  Rev.  deMed.,  1883.  2  These,  Paris,  1874. 

?  Gaz.  med.  des  hop.,  1889.  *  Loc.  cit.,  2d  ed.,  p.  191. 

*  Phila.  Med.  Jour.,  vol.  i. 


196  TYPHOID  FEVER. 

greiit  practical  importance.  This  was  cniphasizctl  by  Griessiuger,  aud 
I  have  frequently  observed  it  as  a  disturbing  factor  during  convales- 
cence. Changes  in  the  penis  appear  extremely  rare.  Complete  or 
partial  gangrene  of  the  organ,  as  has  been  mentioned  by  Andral,  Pill- 
man  n/  and  others,'  I  have  never  observed. 

Female  Genitalia. — As  is  true  of  many  other  infectious  diseases, 
so  the  beginning  and  course  of  typhoid  fever  have  a  definite  influence 
upon  the  menstrual  flow.  It  occurs  quite  frequently  during  the  first 
days  of  the  disease,  and  earlier  than  would  have  been  expected  during 
health.  At  times  it  is  likely  to  be  as  free  as  usual,  and  at  other  times 
imusually  abundant  and  protracted.  In  the  latter  event,  careful  exam- 
ination of  the  genitalia  should  always  be  made,  as  abortion  at  the 
beginning  of  typhoid  fever  may  be  readily  concealed  behind  the  mask 
of  abnormal  menstruation. 

If  the  normal  time  of  menstruation  is  not  due  until  two  to  three 
weeks  after  the  onset  of  the  fever,  the  flow  usually  does  not  take  place. 
In  general,  absence  of  menstruation  is  the  rule  throughout  the  entire 
febrile  period  and  during  the  first  part  of  convalescence  ;  at  Iciist,  this  is 
true  of  protracted  cases  and  those  pursuing  a  severe  course.  I  believe 
that  during  these  periods  complete  absence  of  menstruation  may  be 
expected  in  about  60  per  cent,  of  the  cases.  In  the  remainder,  transi- 
tory, slight,  rarely  profuse  hemorrhage  from  the  genitalia  occurs  in 
rather  an  irregular  manner,  even  during  the  febrile  stage. 

After  severe,  long-protracted  attacks  of  typhoid  fever,  menstruation 
is  likely  to  be  absent  even  after  defervescence,  often  not  appearing  for 
two  or  three  periods.  After  less  severe  and  mild  attacks  it  often  recurs 
during  convalescence.  Profuse  uterine  hemorrhage  at  the  height  of 
the  disease,  without  special  local  cause,  is  rare  and  of  ominous  import. 
It  is  analogous  to  a  similar  occurrence  in  cases  of  hemorrhagic  small- 
pox, and  occurs — rarely,  it  is  true,  in  comparison  with  its  frequency  in 
the  former  disease — in  cases  of  typhoid  fever  presenting  other  "  hemor- 
rhagic "  symptoms.  Toward  the  end  of  the  disease  or  during  conva- 
lescence, peri-uterine  hematocele  may  occur,  as  Trousseau  has  pointed 
out.     Still  far  less  common  than  this  is  hematometra  (Martin  '*'). 

So-called  diphtheric  and  croupous  affections  of  the  uterine  mucous 
membrane,  which,  undoubtedly,  have  nothing  to  do  etiologically  with 
true  diphtheria,  are  of  anatomic  rather  than  of  clinical  interest,  just  as 
are  the  hemorrhage,  the  suppuration,  and  the  necrosis  of  the  ovary,  all 
of  which  during  life  give  rise  to  symptoms  difficult  of  interpretation. 
More  important  are  certain  alterations  in  the  external  genitalia  and 
1  Loc.  cit.  ^  Centralbl.f.  Gyniik.,  1881,  No.  26. 


SYMPTOMS  AND    (JOMPLKJATIONS.  197 

the  vaginal  orifice.  Edema  of  the  labia  minora,  decubital  ulceration  of 
the  greater  and  lesser  labia  and  at  the  vaginal  orifice,  painful  erosions 
at  the  mouth  of  the  urethra,  the  latter  being  not  rarely  the  cause  (^f 
ischuria,  are  of  not  rare  occurrence.  A  form  of  non-gonorrheal  leukor- 
rhea  occurring  with  considerable  frequency  in  the  course  of  typhoid 
fever,  and  which  still  needs  a  thorough  bacteriologic  investigation, 
should  be  mentioned  here. 

In  a  number  of  instances  I  have  observed  acute  inflammation  and 
suppuration  of  the  glands  of  Bartholin.  Takaki  and  Werner '  liave 
reported  such  a  case,  from  the  suppurating  gland  of  which  they  obtained 
the  typhoid-bacillus  in  pure  culture.  Complete  or  partial  gangrene  of 
the  vulva  has  frequently  been  reported  at  different  times  and  in  differ- 
ent epidemics  (Hoffmann,  Liebermeister,  Spillmann  ^).  I  have  observed 
this  condition  in  4  cases,  twice  in  children  and  twice  in  adults. 
In  one  of  the  latter  cases  the  gangrene  was  a  sequel  of  bartholinitis. 
All  clinicians  agree  that  gangrene  of  the  vulva  is  to  be  considered  as  a 
grave  symptom,  occurring  almost  only  in  exceedingly  severe  cases.  In 
the  rare  cases  in  which  it  is  possible  to  demonstrate  a  local  cause,  as 
in  the  case  just  referred  to,  recovery  sometimes  ensues,  then  gener- 
ally with  extensive  cicatricial  defects  extending  into  the  vulva,  or  even 
with  vesical  or  rectal  fistulse. 

Inflammation  of  the  breasts  in  the  course  of  typhoid  fever,  as 
has  been  described  by  Leudet,^  appears  to  be  quite  rare.  Slight  transi- 
tory tumefaction,  however,  is  in  my  experience  somewhat  more  common. 
This  may  readily  be  overlooked,  as  it  usually  occurs  in  severe  cases  at 
the  height  of  the  febrile  stage,  with  the  termination  of  which  it  subsides, 
so  that  the  patient  is  not  really  conscious  of  its  presence,  and  it  is  rarely 
a  source  of  complaint.  Termination  in  suppuration  appears,  as  in  the 
case  of  the  testicle,  the  thyroid  gland,  and  the  parotid  gland,  by  no 
means  to  be  the  rule.  Probably  the  bacillus  of  Eberth  is  the  exciting 
agent  of  the  inflammation  in  the  majority  of  cases.  It  may  be  men- 
tioned that  I  have  observed  slight  mastitis  in  2  cases  of  typhoid 
fever  in  young  men. 

The  relation  between  pregnancy  and  typhoid  fever  is  deserving  of 
full  consideration  from  both  a  clinical  and  a  prognostic  standpoint. 
Reference  has  already  been  made  (under  the  subject  of  Etiology)  to 
predisposition  during  gravidity.  A  study  of  the  literature  of  this  sub- 
ject discloses  differences,  often  actual  contradictions,  which  are  not, 
however,  due  in  the  least  to  the  smallness  of  the  statistics  considered. 

1  Zeit.f.  Hyg.,  Bd.  xxvii.  2  j^^ch.  de  Med.,  1881. 

"*  Clin.  med. 


198  -  TYPHOID  FEVER. 

The  majority  of  writers  give  unfavorable  reports,  stating  that  ahuost 
always  abortion  or  premature  labor  occurs,  with  great  danger  to  the 
life  of  the  mother.  In  my  experience  the  peril  to  pregnant  women 
suffering  from  typhoid  fever  is  not  so  great,  certainly  not  comparable 
to  the  danger  attending  this  condition  in  cases  of  small-pox.  Neverthe- 
less, gravidity  is  to  be  considered  a  serious  complication  of  typhoid 
fever. 

A  number  of  patients  pass  safely  through  the  attack  of  typhoid 
fever  without  interruption  of  pregnancy,  while  others  recover,  in  spite 
of  abortion  or  premature  labor,  in  the  latter  event  at  times  even  with 
a  living  child.  In  other  cases  death  occurs  immediately  after  interrup- 
tion of  the  pregnancy  or  occurs  as  a  result  of  severe  comj^lications.' 
The  cause  of  sudden  death,  often  occurring  within  from  twenty-four  to 
thirty-six  hours,  is  generally  the  large  amount  of  blood  lost.  Among 
the  complications,  septic  conditions  with  pseudodiphtheric  and  gan- 
grenous changes  in  the  uterine  mucous  membrane  should  be  mentioned. 

Miiller  states,  however,  that  typhoid  patients  are  not  more  liable 
than  others  to  complications  of  labor,  such  as  hemorrhage. 

In  my  experience  the  age  of  the  pregnant  woman  and  the  period  in 
pregnancy  have  no  considerable  influence  upon  the  interruption  of  the 
latter,  as  might  be  thought  in  advance.  However,  it  may  be  said  that 
if  the  interruption  occurs  in  the  later  months  of  pregnancy,  the  prog- 
nosis is  distinctly  more  unfavorable  than  if  it  takes  place  during  the 
first  eight  or  ten  weeks.  With  regard  to  the  occurrence  of  this  com- 
plication in  relation  to  the  stage  of  the  disease,  it  may  be  said  that  the 
danger  is  greatest  during  the  febrile  period,  and  that  in  the  first  week 
of  this  period  abortion  occurs  far  less  commonly  than  in  the  second  or 
third  week.  In  protracted  cases  of  typhoid  fever  with  a  markedly 
remittent  or  intermittent  temperature-curve,  I  have  observed  this  com- 
plication occur  as  late  as  the  fourth  week  of  the  fever,  and  even  later. 
If  the  febrile  stage  has  been  successfully  passed,  the  outlook  becomes 
more  favorable.  One  should  avoid,  however,  making  definite  promises 
for  the  period  of  convalescence.  Even  at  this  stage  abortion  and  pre- 
mature labor  occur  sometimes,  especially  in  greatly  reduced  patients  or 
with  the  onset  of  complications. 

As  an  evidence  of  the  remarkable  variability  in  the  statements  of  writers 
with  regard  to  the  course  and  prognosis  of  typhoid  fever  in  gravid  women, 
it  may  be  mentioned  that  Murchison  states  that  the  prognosis  is  always 
grave  in  the  presence  of  advanced  gravidity,  believing  that  a  fatal  termina- 
tion to  premature  labor  invariably  occurs.  Liebermeister  also  considers 
gravidity  as  exceedingly  dangerous.     Of  18  pregnant  women,  he  observed 

^  See  in  the  section  on  Etiology,  the  Conditions  for  Typhoid  Fever  in  the  Fetus. 


SYMPTOMS  AND   COMPLICATIONS.  199 

abortion  in  15  and  death  in  6,  namely,  in  one-third  of  all.  Of  5  pregnant 
women  under  the  observation  of  Griessinger,  8  died,  premature  labor  having 
occurred  in  all.  From  my  Leipsic  statistics,  which,  it  is  true,  include  only 
the  small  number  of  14  cases,  it  appears  that  the  gravidity  was  interrupted 
in  all  but  1,  and  death  occurred  in  5 — 85.6  per  cent.  My  Haml)urg  experi- 
ence, on  the  other  hand,  is  quite  favorable,  and  I  would  attach  some  impor- 
tance to  it,  as  it  is  more  extensive  and  was  obtained  in  the  course  of  a  severe 
epidemic.  Of  all  the  women  coming  under  observation  in  1886-1887,  88 — 
3.4  per  cent. — were  gravid.  Of  these,  3  went  to  term  and  were  delivered 
during  convalescence  of  living  children,  while  14 — 42.1  per  cent. — were 
discharged  after  recovery  from  the  attack  of  typhoid  fever  without  interrup- 
tion of  the  pregnancy.  Pregnancy  was,  thus,  not  threatened  by  the  attack 
of  typhoid  fever  in  exactly  half  of  my  patients.  Of  the  other  patients,  in 
whom  abortion  or  premature  labor  took  place,  3  died.  The  mortality  during 
pregnancy  was  therefore  7.8  per  cent.  I  had,  besides,  a  similarly  favor- 
able experience  at  Berlin  before  the  Hamburg  epidemic.  It  should  be  men- 
tioned, further,  that  results  similar  to  my  own  have  been  reported  from 
Kiel  by  Goth,^  who  among  9  patients  observed  abortion  in  4  and  death  in 
but  1.  Also,  Betz  '^  reports  from  Ziemssen's  clinic  at  Munich  that,  of  9  preg- 
nant women,  abortion  failed  to  occur  in  5. 

Sacquin  ^  collected  from  various  sources  the  statistics  of  233  cases 
of  pregnancy  during  typhoid.  Abortion,  miscarriage,  or  premature 
labor  occurred  in  150  of  these  cases.  Death  occurred  in  37 — 16 
per  cent. 

DIGESTIVE  ORGANS. 

I/ipS,  Mouth,  Tongue,  Pharynx,  Parotid  Glands. — ^While 
during  mild  attacks  these  parts  exhibit  slight  changes  or  alterations 
that  are  not  characteristic,  in  the  severe  and  worst  cases  they  are  likely 
to  acquire  so  peculiar  a  character  as  to  constitute  an  important  part  of 
the  general  clinical  picture.  Even  early  the  mucous  membrane  of  the 
mouth,  lips,  and  tongue  exhibits  a  tendency  to  dryness.  At  the  same 
time  the  latter  is  more  or  less  coated  and  sv^^ollen,  with  distinct  and 
often  deep  impressions  of  the  teeth.  At  the  height  of  the  disease  the 
upper  lip  is  likely  to  be  retracted  and  the  upper  teeth  exposed.  The 
tongue  and  the  lips  then  become  covered  with  a  dirty-brown,  viscid 
deposit,  rapidly  undergoing  desiccation.  The  dry  mucous  membrane  of 
the  lips  becomes  fissured,  the  gums  are  spongy  and  bleeding,  and,  in 
children  who  constantly  pick  at  the  sore  lips,  extensive  eczematous  and" 
ulcerative  processes  readily  develop,  with  marked  swelling  of  the  lips 
and  the  tissues  about  the  mouth.  In  rare  cases  complete  scorbutic 
detachment  and  ulceration  of  the  gums  take  place,  with  at  times  pretty- 
free  hemorrhage. 

The  tongue  at  first  is  frequently  covered  only  in  the  middle  with  a 

1  Inaug.  Diss.,  Kiel,  1886;  and  Deutsch.  Arch.  f.  Jtlin.  Med.,  Bd.  xxxix.,  S.  140. 

2  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  xvi.,  xvii.,  xviii.  ^  These,  Nancy,  1885, 


200  TYI'IIUID   FEVER. 

more  or  less  heavv  whitish  c«r  whitish-yellow  deposit,  while  its  swollen 
margins,  marked  with  the  impressions  of  the  teeth,  are  greatly  reddened. 
In  some  instances  it  may  be  completely  covered  as  early  as  the  first 
week  by  a  tliick  coating,  Avhich  at  times  is  discolored  dirty  brown  or 
even  black  by  food  and  medicine.  During  the  early  })eriod  of  the  dis- 
ease, at  the  beginning  and  the  middle  of  the  first  week,  the  tongue  is 
likely  to  be  still  moist  by  day,  exhibiting  a  tendency  to  dryness  only 
toward  evening  and  night.  In  the  second  week  of  severe  cases  it  can 
be  kept  moist  only  with  great  care ;  it  is  then  extended  with  difficulty 
and  is  tremulous ;  it  appears  less,  if  at  all,  swollen,  and  in  less  well- 
cared-for  patients  is  brown,  dry,  encrusted  and  fissured,  and  bleeds 
readily  from  the  fissures.  The  coating  of  the  tongue  disappears  at  a 
time  depending  upon  the  character  of  the  individual  case,  but  usually 
at  the  end  of  the  second  or  in  the  beginning  of  the  third  week,  usually 
disappearing  first  at  the  tip  in  the  form  of  a  triangle  and  at  the  mar- 
gins, then  over  the  entire  tongue,  so  that  the  organ  then  appears 
smooth,  red,  dry,  and  thin,  and  more  pointed  than  usual. 

Several  factors  are  responsible  for  the  ominous  dryness  of  the  tongue, 
namely,  the  febrile  temperature,  the  diminution  in  salivary  secretion, 
constantly  keeping  the  mouth  open,  and  the  diminished  desire  of  the 
somnolent  patient  to  moisten  the  organ.  Typhoid  patients  with  a  dry 
tongue  always  exhibit  more  or  less  marked  derangement  of  conscious- 
ness. The  tongue  in  cases  of  tj^phoid  fever  does  not  exhibit  any  dis- 
tinctive morbid  manifestations.  Its  alterations  become  characteristic 
only  from  the  period  of  onset,  the  intensity,  and  the  arrangement.  An 
early  appearance  and  a  tendency  to  dryness  of  the  tongue  are  of  diag- 
nostic importance.  They  represent  a  conspicuous  associated  feature  of 
the  t}^hoid  state. 

McCrae^  has  reported  a  case  of  glossitis  coming  on  during  con- 
valescence from  typhoid  fever.  The  onset  was  on  the  twenty-fifth 
day  of  normal  temperature,  and  ^A'ith  it  occurred  a  typical  relapse 
lasting  two  weeks.  Recovery  was  complete.  He  has  also  collected 
several  other  cases  from  the  literature. 

Of  peculiar  changes  in  the  mucous  membrane  of  the  mouth  and  the 
pharynx,  deposits  of  thrush  especially  are  to  be  mentioned.  These 
occur  only  in  extremely  severe,  protracted  cases,  or  in  patients  who  have 
been  previously  ill,  and  in  whom  the  care  of  the  mouth  has  been 
neglected.  Under  such  circumstances  I  have  seen  the  deposits  extend 
dow^n  the  esophagus  to  the  region  of  the  cardia,  and  even  to  constitute 
a  serious  obstruction  to  breathing.  The  occurrence  of  a  severe  case  of 
*  Johns  Hopkins  Hasp.  Bull.,  vol.  ix. 


SYMPTOMS  AND   COMPLiaATIONS.  201 

■>thriish  iu  a  hospital  does  not  reflect  creditably  upon  the  medical  care 
and  the  nursing. 

The  structures  of  the  fauces  exhibit  various  changes  in  cases 
of  typhoid  fever.  Lymphoid  swelling  of  the  tonsils  and  the  })alatine 
arches — to  which  reference  has  already  been  made  (in  the  chapter 
on  Anatomy) — appears  to  me  to  be  rarely  demonstrable,  at  least  clin- 
ically. Duguet  and  Chantemesse  have  observed  such  infiltrations 
undergo  disintegration  with  the  subsequent  formation  of  ulcers,  in  the 
floor  of  which  typhoid-bacilli  were  demonstrable — a  process,  therefore, 
that  is  probably  comparable  to  the  specific  lesion  in  the  intestines. 

In  the  large  majority  of  cases  there  is  but  slight  involvement  of 
the  pharyngeal  structures,  namely,  moderate  swelling,  and  frequently 
cloudiness  of  the  mucous  membrane  of  the  soft  palate,  the  tonsils,  and 
the  posterior  pharyngeal  wall.  In  the  second  and  third  weeks  the 
pharyngeal  structures  participate  in  the  dryness  of  the  remainder  of 
the  mouth.  They  are  then  profusely  covered  with  exceedingly  viscid 
mucus,  readily  desiccating  into  crusts  and  filaments,  and  occasionally 
becoming  a  serious  obstruction  to  swallowing  and  breathing. 

It  is  exceedingly  important  to  realize  that  symptoms  of  angina  may 
be  present  as  early  as  the  beginning  of  the  first  week  of  typhoid 
fever,  and  that,  together  with  chilliness  and  slight  elevation  of  tempera- 
ture, may  at  times  constitute  the  earliest  and  the  only  manifestation 
causing  the  patient  any  inconvenience.  Under  such  circumstances  the 
mucous  membrane  of  the  pharynx  and  the  tonsils  appears  more  or  less 
markedly  reddened  and  spongy.  In  addition  there  are  not  rarely 
present  upon  the  soft  palate,  the  palatine  arches,  and  the  tonsils  isolated, 
rarely  numerous,  whitish,  at  times  slightly  elevated  spots,  varying  in 
size  from  that  of  a  lentil  to  that  of  a  pea,  which  represent  areas  of 
circumscribed  granular  clouding  and  tumefaction  of  the  uppermost 
layer  of  the  mucous  membrane.  Generally  in  the  course  of  a  few 
hours  superficial  exfoliation  takes  place,  leaving  quite  shallow  reddish 
erosions,  covered  with  a  thin  whitish  deposit  and  surrounded  by  a  flat, 
irregular,  often  vividly  reddened  margin,  which  is  never  infiltrated.  If 
the  parts  are  kept  sufficiently  moist  and  clean,  the  lesions  do  not 
further  increase  in  size  and  depth,  and  they  have  almost  always  dis- 
appeared at  the  beginning  of  the  second  week. 

At  times  this  affection  of  the  throat  becomes  so  prominent  as  to  give  rise 
to  error  in  diagnosis.  I  have  in  2  instances  observed  such  patients 
admitted  to  the  hospital  with  a  diagnosis  of  diphtheria  and  croup,  respec- 
tively. In  one  instance  incipient  scarlet  fever  was  suspected  because  of 
the  associated  presence  of  a  slight  initial  rash.     In  another  case  in  which 


202  TYPHOID  FEVER. 

the  affection  of  the  throat  existed  together  with  au  abundant  roseolous  erup- 
tion upon  the  trunk,  a  diagnosis  of  syphilis  was  made. 

Typhoid  angina  was  evidently  known  to  earlier  writers ;  at  any  rate, 
certain  statements  made  by  Louis,  Jenner,  and  Chomel  with  regard  to  early 
involvement  of  the  pharyngeal  structures  in  cases  of  typhoid  fever  are  indi- 
cative of  this.  Subsequently  it  disappeared  for  a  time  from  the  literature  and 
the  memory  of  physicians,  in  part,  perhaj)s,  because  it  varies  extremely  in  fre- 
quency, at  different  times,  and  in  diflereut  places.  Thus,  I  observed  it  quite 
rarely  in  the  years  in  which  typhoid  fever  prevailed  extensively  in  Ham- 
burg, while  it  came  under  my  observation  with  remarkable  frequency  and 
in  marked  degree  at  certain  times  in  Leipsic.  So  far  as  I  know,  this  variety 
of  angina,  which  possesses  a  certain  degree  of  importance  as  an  early  mani- 
festation of  typhoid  fever,  has  not  yet  been  studied  bacteriologically.  This 
might  prove  an  interesting  undertaking  that  would  possibly  yield  diagnostic 
results. 

Actual  diphtheric  affections  of  the  pharyngeal  structures,  such  as  have 
been  described  by  Griessiuger,  Oulmond/  and  others,  at  the  height  of 
the  disease,  toward  the  close  of  the  second  or  in  the  third  week,  are  proba- 
bly to  be  included  among  the  true  complications.  In  any  event,  they 
are  extremely  rare  occurrences  that  yet  require  exact  bacteriologic  inves- 
tigation. I  have  personally  not  as  yet  encountered  a  case  of  this  kind. 
The  extension  of  the  affections  of  the  throat  above  described  to  the  naso- 
pharyngeal space,  the  Eustachian  tubes,  and  the  middle  ear  will  be 
considered  at  another  place. 

The  alterations  in  the  parotid  gland,  and  especially  the  inflammatory 
lesions  of  this  organ,  in  cases  of  typhoid  fever  are  quite  important, 
even  though  they  are  not  so  common  as  they  are  generally  believed 
to  be.  As  is  so  often  the  case  with  especially  painful  and  conspicuous 
disorders,  the  frequency  of  parotitis  has  been  greatly  overestimated.  I 
have  personally  determined  that  during  the  Hamburg  epidemics  only 
0.3  per  cent.,  and  in  Leipsic  0.5  per  cent.,  of  the  patients  exhibited 
inflammation  of  the  parotid  glands  ;  and  in  the  statistics  of  Hoffmann 
relating  to  the  Basle  epidemic,  parotitis  was  noted  in  16  of  1600 
cases — 1  per  cent.  Recently  parotitis  appears  to  have  become  even  less 
common,  and  this  is  probably  due,  in  part  at  least,  to  the  greater  care 
given  generally  to  the  mouth  of  the  patients. 

Parotitis  develops  generally  on  one  side ;  rarely  both  glands  are 
involved  synchronously,  while  disease  of  both  successively  is  more 
common.  Parotitis  is  usually  a  manifestation  at  the  height  of  the 
disease,  toward  the  end  of  the  second  or  the  third  week,  although  it 
may  come  under  observation  also  later,  and  even  during  convalescence. 
Its  clinical  features  are  scarcely  different  from  those  of  inflammation  of 
the  glands  under  other  conditions.  The  affection  usually  occurs  in  very 
^  Rev.  de  med.  et  chir.  de  Paris,  J^^')  1855. 


SYMPTOMS  AND   COMPLICATIONS.  203 

ill  and  already  much  reduced  individuals,  which  fact  has  an  important 
bearing  on  the  course  and  symjstoms  of  the  complication.  In  the  majfjrity 
of  cases  the  retromandibular  portion  first  becomes  swollen,  after  which, 
with  few  exceptions,  the  entire  organ  is  involved.  The  affection  is  so 
painful  that  even  profoundly  soporose  patients  are  conscious  of  its 
existence.  But  rarely,  and  then  in  cases  of  metastatic  origin,  it  sets  in 
with  a  chill,  while  a  corresponding  elevation  of  temperature  without  a 
chill  is  observed  almost  unexceptionally.  The  affection  may,  as  I  have 
repeatedly  observed,  subside  without  suppuration,  even  after  consider- 
able tenderness,  swelling,  and  redness  have  been  present.  When  sup- 
puration occurs,  as  it  does  in  most  cases,  it  involves  at  times  but  one 
portion  of  the  inflamed  gland,  and  at  other  times  the  entire  organ.  In 
the  latter  event  I  have  occasionally  been  able  to  extract  from  the 
incision  wound  large  portions  of  the  connective-tissue  structure  of  the 
gland  in  the  form  of  necrotic  shreds. 

With  regard  to  the  mode  of  origin  of  typhoid  parotitis,  the  view  of 
Virchow,^  that  it  is  due  to  extension  of  infectious  processes  from  the 
mouth  through  the  duct  of  Stenon  to  the  gland,  is  certainly  correct  for 
some  cases.  In  several  cases  I  have  observed  parotitis  occiu'  in  associa- 
tion with  ulcerative  stomatitis,  especially  in  the  vicinity  of  the  papilla 
of  Stenon.  Above  all,  it  should  be  kept  in  mind  that  the  glands 
are  more  frequently  directly  involved  in  consequence  of  the  action  of 
the  typhoid  toxins  than  are  other  organs  (see  section  on  Anatomy). 
Also,  the  typhoid-bacilli  themselves  may  in  some  cases  be  the  direct 
excitants  of  the  inflammation.  At  least  1  case  has  been  reported 
( Janowski  ^)  in  which  a  pure  culture  of  the  typhoid-bacillus  was  ob- 
tained from  the  suppurating  gland.  In  a  number  of  other  cases  the 
typhoid-bacillus  has  been  associated  with  the  pyogenic  cocci  (Anton 
and  Flitterer^).  In  a  number  of  instances  I  have  been  able  to  demon- 
strate the  presence  of  staphylococci  exclusively  in  the  pus  obtained  by 
puncture  of  the  gland  during  life.  Exceptionally,  I  have  obsers^ed 
parotitis  as  one  of  the  symptoms  of  a  complicating  general  septicemia. 
Although  earlier  writers  report  the  observation  of  this  occurrence  more 
frequently,  this  may  be  due  to  the  fact  that  the  term  septicemia  was 
given  a  wider  interpretation  than  appears  justified  at  the  present  day. 
I  have  also  in  a  number  of  instances  seen  parotitis  as  the  sole  metastatic 
manifestation,  without  the  development  of  general  pyemia,  particularly 
following  suppurative  enteritis  in  cases  of  typhoid  fever.  I  can  recall, 
for  instance,  having  observed  metastatic  abscess  of  the  parotid  gland  in 

i  Charite-Annalen,  1858.  2  Centralhl.  f.  Bact,  Bd.  xvii, 

=»  Munch,  med.  Woch.,  1888,  No.  19. 


204  TYPHOID  FEVER. 

2  cases  following  typln)id  perityphlitis.  In  1  of  these  cases  the 
affection  was  bilateral. 

In  general,  parotitis  is  one  of  the  severe  and  dangerous  complications 
of  typhoid  fever.  Liebermeistcr,'  among  210  fatal  cases  between  1865 
and  1868,  observed  parotitis  in  6 — 2.8  per  cent.  Of  the  16  cases  of 
parotitis  reported  by  Hoffmann,  to  which  reference  has  previously  been 
made,  death  occurred  in  9.  Of  28  cases  collected  by  Keen,'^  8  were 
fa  till.  Among  the  serious  consequences,  thrombosis  of  the  jugular  vein 
and  the  cerebral  sinuses  and  acute  edema  of  the  brain  are  to  be  men- 
tioned. As  a  result  of  direct  extension  of  the  suppuration,  periostitis  and 
necrosis  of  the  adjacent  bones,  suppuration  of  the  masseters,  burrowing 
of  the  pus  betw^eeu  the  superficial  and  deep  fascire  of  the  neck,  in  the 
latter  event  with  the  development  of  mediastinitis,  may  take  place. 
Secondary  pyemia  is  a  possibility  under  such  conditions.  In  1  instance 
I  observed  incurable  facial  palsy  (see  also  Griessinger  and  Liebermeister). 

Stomach  and  Bsophagiis. — Although  it  is  extremely  rare  that 
the  stomach  and  the  esophagus  exhibit  specific  alterations,  and  almost 
never  give  rise  to  characteristic  symptoms,  they  do,  especially  at  the 
beginning  of  the  attack,  play  a  certain  role.  It  will,  at  any  rate,  be 
well  to  devote  a  few  words  to  the  consideration  of  such  general  and 
indefinite  symptoms  as  the  pain  in  the  epigastrium,  the  nausea,  and 
the  vomiting.  Nervous  individuals  frequently  complain  of  a  sense  of 
didl  pressure  in  the  epigastrium  from  the  prodromal  stage  into  the  first 
week  of  the  disease.  This  sensation  almost  never  attains  to  the  inten- 
sity of  the  dominating  pains,  such  as  are  characteristic  of  the  first  days 
of  other  infectious  diseases,  particularly  variola.  Severe  pain  in  the 
epigastrimn,  therefore,  at  a  period  in  the  course  of  a  febrile  disease 
when  the  diagnosis  is  uncertain  is  against  rather  than  in  favor  of 
typhoid  fever.  From  the  second  week  on,  the  complaints  of  epigastric 
oppression  yield  to  the  progressive  somnolence. 

Also,  vomiting  and  nausea  by  no  means  play  the  role  in  the  beginning 
of  typhoid  fever  that  they  do  in  that  of  typhus  fever  and  variola.  I 
have  observed  them  most  frequently  at  the  beginning  of  the  disease  in 
children,  in  ners^ous  women  or  hysterical  men ;  but  under  such  circum- 
stances they  appear  generally  as  a  transitory  featm-e,  and  almost  never 
become  severely  spasmodic  or  colicky.  In  some  instances  the  attacks 
of  vomiting  appeared  not  to  be  induced  by  irritation  in  the  stomach, 
but  by  the  anginose  lesions  previously  mentioned.  In  such  cases  they 
may  be  continued  into  the  second  week.  Severe  and  repeated  vomiting 
at  the  height  of  the  disease  should  suggest  the  possibility  of  certain 
^  Betke,  Inaug.  Diss.,  Basle,  1870.  ^  Loc.  cit. 


SYMPTOMS  AND   COMJ'LICATIONS.  205 

complications,  such  as.  meningitis  and  allied  conditions,  perforation  of 
the  bowel,  peritonitis,  and,  finally,  latent  intestinal  hemorrhage.  After 
defervescence  and  during  convalescence,  nausea  and  vomiting  are  almost 
always  referable  to  dietetic  error.  Some  writers  refer  to  the  occurrence 
of  severe,  almost  uncontrollable  vomiting  during  convalescence,  for 
which  no  adequate  anatomic  basis  could  be  found  at  autopsy.  I  have 
observed  this  manifestation,  which  I  believe  to  be  extremely  rare,  only 
in  cases  of  protracted  course  with  severe  complications.  In  1  case, 
which  from  the  other  symptoms  was  to  be  considered  as  one  of  hem- 
orrhagic typhoid,  I  found  erosive  gastritis  with  nmnerous  ecchymoses 
as  the  anatomic  explanation  of  the  vomiting. 

The  appetite  is  wholly  lost  in  most  cases  as  early  as  the  prodromal 
stage,  and  in  all  during  the  first  week.  The  patients  acquire  an 
aversion,  even  a  disgust,  for  the  ingestion  of  food,  and  complain  of  a 
stale,  pasty,  acid  or  bitter  taste,  and  of  a  sense  of  burning  thirst.  At 
the  height  of  the  disease  these  subjective  manifestations  disappear,  and 
the  patients  swallow  mechanically  what  is  proffered  them,  at  times,  it  is 
true,  with  some  resistance.  In  a  word,  during  the  period  of  evolution 
and  at  the  height  of  the  disease,  the  state  of  the  appetite  is  the  same  as 
in  most  infectious  diseases.  The  conditions  are  different,  however, 
during  the  period  of  involution  and  in  convalescence.  In  children  and 
in  young  adults  a  marked  almost  uncontrollable  sense  of  hunger  makes 
its  appearance  during  the  stage  of  steep  curves.  In  nervous  women 
and  in  elderly  persons  the  appetite  is,  on  the  other  hand,  generally 
wanting  at  this  period.  During  convalescence,  however,  impairment  or 
want  of  appetite  is  the  exception  in  all  patients.  Only  exceedingly  sensi- 
tive individuals  and  those  who  suffer  from  the  consequences  of  certain 
severe  complications  are  still  indifferent  or  averse  to  food  and  drink  at 
this  time.  Well  known  are  the  large  eyes  with  which  those  convalescent 
from  typhoid  fever  constantly  look  about  for  food  and  mth  which  they 
follow  anyone  from  whom  they  hope  fulfilment  of  this  controlling 
desire.  The  appetite,  almost  always  prematurely  large  in  relation  to 
the  state  of  the  intestinal  lesion,  often  brings  the  physician  in  conflict 
with  the  patient  and  injudicious  relatives.  Even  in  the  physician 
there  may  be  a  struggle  between  the  sense  of  duty  and  conviction  and 
the  feeling  of  sympathy. 

1  recall  a  boy,  thirteen  years  old,  who,  during  protracted  convalescence 
from  an  attack  of  typhoid  fever,  was  provided  food  to  the  utmost  limit  of  the 
permissible,  and  then  requested  his  sisters  to  come  to  his  bedside  to  eat 
in  order  that  he  might  at  least  be  able  to  see  them  dispose  of  their  huge 
slices  of  bread  and  butter. 


206  TYPHOID  FEVER. 

lu  the  consideration  of  the  anatomic  alterations  reference  was  made 
to  certain  organic  lesions  in  the  stomach  that  are  encountered  in  cases 
of  typhoid  fever.  These  are  scarcely  attended  with  special  clinical 
manifestations. 

Bouchard  aud  his  pupil,  Legendre,'  have  called  attention  to  the  fact  that 
typhoid  fever  ami  dilatation  of  the  stomach  are  so  frequently  associated  that 
a  tlirect  coimection  between  the  two  must  be  thoufj^ht  of  Both  of  these 
writers  believe  not  only  that  dilatation  of  the  stomach  may  be  the  result  of 
typhoid  fever,  but  also  that,  conversely,  existing  dilatation  of  the  stomach 
favors  typhoid  infection.  The  fact  that  individuals  attacked  several  times 
by  typhoid  fever  frequently  suffer  from  dilatation  of  the  stomach  is  thought 
to  be  especially  convincing.  So  far  as  I  know,  these  statements  have  not 
yet  been  confirmed  in  the  German  literature.  Personally,  from  my  own 
experience,  I  am  unable  to  verify  them. 

Reference  has  already  been  made  to  the  superficial  erosions  and  ulcers 
sometimes  seen  in  the  esophagus  after  death.  These  rarely  give  rise  to 
symptoms.  In  the  case  of  esophageal  ulceration  reported  by  Mitchell,'^  how- 
ever, for  two  days  before  death  there  was  well-marked  dysphagia.  Several 
cases  of  esophagismus  during  typhoid  fever  have  been  reported,  but  it  is  not 
known  whether  this  has  any  anatomic  basis.  No  cases  of  hematemesis  asso- 
ciated with  esophageal  lesions  have  been  reported.  Several  cases  of  stricture 
of  the  esophagus  following  typhoid  fever  have  occurred.  This  is  usually  a 
late  sequel,  but  the  onset  of  symptoms  may  be  during  convalescence,  as  in 
the  case  reported  by  Summers.^ 

lyiver  and  Biliary  Passages. — The  liver  and  the  biliary  pas- 
sages also  jday  no  prominent  role  in  the  ordinary  symptomatology  of 
tyjjhoid  fever.  Especially  subjective  symptoms  referable  to  them  are 
extremely  rare.  Objectively,  at  the  height  of  the  disease,  the  region  of 
the  liver  is  occasionally  tender  on  pressure,  associated  with  enlargement 
of  the  organ,  usually  of  moderate  grade  and  probably  due  to  hyperemia 
and  cloudy  swelling.  It  is  further  to  be  noted  that,  in  a  majority 
of  all,  even  severe,  cases  of  typhoid  fever,  providing  they  are  uncom- 
plicated, the  liver  generally  does  not  continuously  exceed  its  normal 
size.  So  flir  as  is  known,  the  focal  necroses  previously  mentioned  give 
rise  to  no  symptoms. 

Icterus  is,  in  the  opinion  of  most  experienced  observers,  among 
whom  Murchison,  Griessinger,  and  Liebermeister  may  be  mentioned,  an 
especially  rare  manifestation  in  the  course  of  typhoid  fever — so  rare 
that  some,  as,  for  instance,  Fiedler,  with  reference  to  AVeil's  disease,  con- 
siders this  fact  properly  of  significance  in  differential  diagnosis.  Possibly 
this  manifestation,  which  is  common  in  some  other  infectious  diseases, 
and  then  principally  due  to  duodenal  catarrh,  is  so  rare  in  cases  of 
typhoid  fever  because  in  this  disease  the  stomach  and  the  upper  por- 

^  "Dilatation  de  I'estomac  et  fievre  typhoide, "  etc.,  These^  Paris,  1886. 

2  Johns  Hopkins  Hosp.  Rep.,  vol.  viii.         ^  Phila.  Med.  Jour.,  Oct.  28,  1899. 


SYMPTOMS  AND   COMPLfCAT/ONS.  207 

tions  of  the  intestine  are  but  little  involved  in  the  morbid  process. 
Also,  another  condition  favoring  the  development  of  icterus  in  some 
infectious  diseases,  namely,  marked  acute  swelling  of  the  parenchyma 
of  the  liver  and  consecutive  interlobular  biliary  stasis,  is  encountered 
with  extreme  rarity  in  cases  of  typhoid  fever. 

Liebermeister  observed  jaundice  but  26  times  in  1420  cases  and 
Osier  has  seen  it  but  5  times  in  830  cases.  Its  frequency  seems  to 
vary  in  different  epidemics,  as  Da  Costa,'  in  1898,  reported  5  cases 
from  the  Pennsylvania  Hospital,  4  of  which  he  had  seen  within  a  few 
months.  He^  has  analyzed  52  cases  from  the  literature.  The  probable 
causes  of  the  jaundice  in  these  cases  were  :  catarrhal,  4 ;  pylephlebitis 
3 ;  cholecystitis,  5  ;  abscess,  6  ;  acute  yellow  atrophy,  5 ;  toxic,  24  • 
uncertain,  5. 

According  to  Osler,^  the  cases  of  jaundice  occurring  in  typhoid  fever 
may  be  grouped  in  four  categories  :  (1)  catarrhal ;  (2)  toxic ;  (3)  those 
associated  with  abscess;  (4)  those  associated  with  gall-stones  and 
cholangitis. 

Catarrhal  Jaundice.— Osier  thinks  that  the  slight  jaundice  in 
cases  of  moderate  severity  is  of  this  form,  and  under  this  heading  he 
includes  6  of  the  8  cases  reported  by  him.  Da  Costa,  however,  thinks 
that  most  of  the  cases  are  of  toxic  origin,  as  he  includes  only  4  of  the 
52  cases  under  the  catarrhal.  It  is  interesting,  in  this  connection,  that 
clay-colored  stools  are  of  rare  occurrence.  They  were  not  clay  colored 
in  4  of  the  5  cases  reported  by  Da  Costa,  and  in  only  1  of  Osier's 
cases  is  the  presence  of  clay-colored  stools  mentioned.  In  favor  of 
many  of  these  milder  cases  being  of  catarrhal,  obstructive  origin  is  the 
great  frequency  with  which  the  bacilli  are  present  in  the  bile.  The 
quite  constant  occurrence  of  typhoid-ljacilli  in  the  gall-bladder  in  cases 
of  experimental  inoculation-typhoid  in  rabbits  was  noted  by  Blachstem  * 
in  1891.  After  Gilbert  and  Girode^  had  demonstrated  the  typhoid- 
bacilli  in  the  human  gall-bladder,  Chiari «  showed  the  almost  constant 
occurrence  of  the  bacillus  of  Eberth  in  the  gall-bladder— in  20  of 
22  autopsies — often  in  enormous  numbers.  Chiari's  observations  have 
been  confirmed  by  Birch-Hirschfeld  ^  and  others.  In  most  cases  they 
cause  no  damage  to  the  gall-bladder  or  ducts.  That  they  probably 
induce  more  severe  forms  of  inflammation  and  may  lead  to  the  forma- 

1  Trans,  of  Assoc.  Am.  Phys.,  vol.  xiv.  2  Ibid.,  vol.  xiii. 

^  Johns  Hopkins  Hosp.  Rep..^  vol.  viii. 

*  Johns  Hopkins  Hosp.  Bull.,  1891,  vol.  ii. 

°  Sem.  med.,  1890,  No.  58,  and  Compt.  rend,  de  la  soc.  biol.,  1891,  No.  11. 

«  Prag.  med.   Woch.,  1893,  No.  22. 

^  Path.  Anat,  Bd.  ii.,  4.  Aufl.,  S.  694. 


208  TYPHOID  FEVER. 

tien  of  calculi  ^\ill  be  spokeu  of  later.  Whether  they  can  induce  a 
mikl  form  of  catarrh  of  the  ducts,  and  so  lead  to  au  obstructive  catarrhal 
jaundice,  is  uot  yet  dcliuitcly  settled.  As  we  know,  however,  how  the 
presence  of  typhoid-bacilli  in  the  urine  may  give  rise  to  the  mildest 
form  of  cystitis,  as  shown  only  by  the  presence  of  a  few  pus-cells  in 
the  urine,  as  well  as  to  the  more  severe  grades  of  cvstitis,  it  seems 
probable  that  a  similar  condition  can  occur  with  regard  to  the  bile,  and 
that  a  simple  catarrhal  inflammation  may  be  set  up  that  induces  these 
milder  grades  of  jaundice. 

Toxic  Jaundice. — In  lavor  of  the  view  that  many  of  the  cases 
are  of  this  form,  Da  Costa  presents  these  arguments  :  ''  Its  occurrence, 
as  a  rule,  as  a  late  symptom  and  in  grave  cases;  the  character  of  the 
stools,  which  are  but  little  modified ;  the  general  similarity  to  the 
jauntUce  noticed  in  other  infective  diseases  and  altered  blood  states, 
such  as  in  pyemia.  The  condition  of  the  liver  itself  does  not  give  us 
much  information.  Yet  where  the  organ  has  been  carefully  examined, 
it  has  been  found  to  show  degeneration  of  the  liver-cells  that  has  been 
likened  by  Frerichs  even  to  the  state  found  in  acute  yellow  atrophy." 

Such  a  case,  nmning  a  course  like  acute  yellow  atrophy,  with,  at 
autopsy,  a  liver  resembling  that  found  in  that  condition,  has  been  lately 
reported  by  Sauborin.  Reference  has  also  been  made  to  this  condition 
by  Griessinger,  Liebermeister,  and  Hoifmann.  When  this  rare  con- 
dition occurs  at  all — I  am  unfamiliar  with  it  from  personal  observa- 
tion— it  is  said  to  appear  at  the  height  of  the  typhoid  process,  at  times 
in  association  with  distinct  painful  tmnefaction,  and  then  rapidly  pro- 
gressive diminution  in  the  size  of  the  liver.  Jaundice  soon  appears, 
together  with  hemorrhages  from  various  organs,  hematuria  and  albu- 
minuria,  cardiac  weakness,  and  death  in  coma. 

Abscess  of  the  I/iver. — Da  Costa  has  collected  22  cases  in 
which  the  association  of  abscess  of  the  liver  with  typhoid  fever  seemed 
beyond  doubt.  Of  these,  only  7  had  jaimdice,  but  in  12  it  is  not  men- 
tioned at  all.  I  know  of  no  cases  in  which  the  abscesses  are  due  to  a 
localization  of  the  typhoid-bacilli  in  the  liver.  Abscess  of  the  liver 
may  arise  in  three  different  ways  :  (1)  As  one  of  the  manifestations  of 
general  secondary  septicemia  or  pyemia  complicating  typhoid  fever ;  (2) 
as  a  result  of  septic  pylethrombosis,  in  connection  with  suppurative 
affections  of  the  intestine,  especially  the  cecum ;  finally,  (3)  in  conse- 
quence of  various  inflammatory  and  ulcerative  processes  in  the  large 
biliary  passages  and  the  gall-bladder. 

I  have  personally  observed  instances  of  all  three  modes  of  origin.  An 
instance  of  the  first  variety  consists  in  the  case  of  a  man,  twenty-three  years 


SYMPTOMS  AND   COMPLICATIONS.  209 

old,  who  pi'esented  3  abscesses,  from  the  size  of  a  pigeon's  to  that  of  a 
hen's  egg,  in  the  right  lobe  of  the  liver,  doubtless  due  to  a  deeply  under- 
mined putrid  bed-sore.  A  similar  condition  has  been  observed  by  Louis ' 
and  Chvostek,^  the  former  in  the  setjuence  of  su])purative  parotitis,  and  the 
latter  after  perichondritis  of  the  larynx.  Osier  lias  reported  such  a  case,  in 
which,  in  addition  to  the  abscess  of  the  liver,  there  occurred  suppuration  in 
the  parotid  gland,  abscess  of  the  gastrohepatic  lymph-glands,  and  multiple 
lung-abscesses.  I  have  observed  2  cases  belonging  in  the  second  category,  the 
first,  in  1887,  in  private  practice.  In  this  case  an  abscess  developed  in  the 
right  iliac  fossa  as  a  sequence  of  typhoid  perityphlitis,  and  it  gave  rise  to 
an  irregular,  bulging  abscess,  as  large  as  an  apple,  in  the  left  lobe  of  the 
liver,  attended  with  chills  and  characteristic  intermittent  fever,  and  termi- 
nating fatally.  The  second  case,  reported  from  my  clime  by  Romberg, '  like- 
wise originated  from  a  suppurative  perityphlitis,  and  gave  rise  to  multiple 
abscesses  of  the  liver  in  the  distribution  of  the  portal  vein.  Bacteriologic 
examination  disclosed  the  presence  of  staphylococci  only,  and  no  typhoid- 
bacilli,  in  the  pus.  Klebs  *  has  probably  reported  the  first  instance  of  the 
development  of  abscess  of  the  liver  from  ulceration  of  the  biliary  passages. 
A  case  under  my  observation  occurred  in  a  woman,  eighteen  years  old,  with 
an  encapsulated  abscess  at  the  side  of,  and  behind,  the  gall-bladder,  which 
communicated  with  it,  extending  to  the  size  of  a  pigeon's  egg  into  the  sub- 
stance of  the  liver.  The  condition  had  developed  at  the  commencement 
of  the  fourth  week  of  the  attack  of  typhoid  fever,  and,  what  made  the 
diagnosis  most  difficult,  it  was  at  the  beginning  unattended  with  jaundice, 
and  later  was  attended  with  but  slight  jaundice. 

The  typhoid  inflammatory  affections  of  the  gall-bladder 
and  large  biliary  passages  are  deserving  of  thorough  consideration. 
Such  occurrences  were  mentioned  by  Andral,  Louis,  Jenner,  and  Leudet, 
and  subsequently  were  described,  especially  by  Rokitansky,  as  diphtheric 
affections  of  the  gall-bladder.  Later  German  and  French  writers  also 
refer  to  them,  generally  as  ulcerative  pseudomembranous  affections, 
terminating  in  abscess  of  the  liver,  perforative  peritonitis,  etc.  Chole- 
cystitis and  cholangitis  in  typhoid  fever  have  been  more  fiilly  treated  of 
in  the  past  few  years  by  Osler,^  Mason/  Da  Costa,''  Camac,^  Ryska,^  and 
others.  These  authors  have  collected  and  reported  numerous  cases  in 
which  these  conditions  occurred  either  as  complications  or  as  sequels. 
As  to  the  frequency  of  acute  cholecystitis  during  the  febrile  attack,  no 
considerable  statistics  have  been  collected,  although  quite  numerous  cases 
have  been  reported  by  the  above-mentioned  writers.     With  regard  to 

1  Loc.  ciL,  1841,  2d  ed.,  vol.  i.  2  Allg.   Wien.  med.  Zeit.,  1866,  '^o.  37. 

3  Berlin,  klin.  Woch.,  1890,  iSTo.  9.  This  article  contains  an  extensive  bibliog- 
raphy. Of  similar  cases,  there  are  cited  that  of  Tiingel,  Klin.  Mittheil.,  Hamburg, 
1862-18G3;  that  of  Asch,  Berlin.  Hin.  Woch.,  1882,  No.  51;  and  that  of  Buckling, 
Inaufj.  Diss.,  Berlin,  1868. 

*  Handbuch  der  path.  Anat,  1868,  p.  480. 

"  -^oc.  cit.  6  Trans.  Assoc.  Am.  Phvs.,  vol.  xii. 

Loc.  cit.  8  Johns  Hopkins  Hosp.  Rep.,  vol.  viii. 

^  Munch,  med.  Woch.,  Bd.  Ivi.,  No.  23. 
14 


210  TYPHOID  FEVER. 

the  etiology,  it  may  be  said  tliat  in  a  number  of  tlie  oases  in  -vvhieh  bac- 
teriologic  examinations  "were  made,  pure  cultures  of  the  typhoid-bacilhis 
Avere  obtained.  But,  as  from  the  work  of  Cliiari  and  others,  tlie  ahiiost 
constant  presence  of  the  typhoid-bacilli  iu  the  gall-bladder  has  been 
demonstrated,  there  ■  must  be  some  secondary  factor.  Recent  studies 
leave  no  doubt  that  gall-stones  render  the  biliary  ducts  and  gall-bladder 
more  rece])tive  to  infection.  But  Avhile  stones  have  been  found  in  some 
of  these  acute  eas(;s,  iu  the  majority  they  have  not  been  present.  Of 
74  cases  of  biliary  infection  collected  by  Keen,  in  38  no  gall-stones 
were  found.  In  34  cholecystitis,  empyema,  or  ulceration  was  present 
without  gall-stones,  and  from  11  the  typhoid-bacillus  was  isolated.  It 
is  probable  that  in  many  cases  the  obstruction  to  the  flow  of  bile  is  due 
to  nnicus ;  the  growth  of  the  bacteria  being  thus  favored,  an  acute 
iuflammation  (_)f  the  walls  of  the  gall-bladder  may  be  induced,  leading 
to  suppuration,  distention,  possibly  ulceration  and  perforation. 

The  main  symptoms  of  cholecystitis  are  localized  pain  and  tender- 
ness and  the  presence  of  a  tumor.  The  tumor  is  usually  located  in  the 
right  hypochondrium,  but  may  be  much  louver,  even  below  the  umbili- 
cus. Jaundice  may  occur,  but  is  by  no  means  constant.  Further  and 
more  complete  observations  as  to  the  behavior  of  the  leukocytes  are 
needed.  Surgical  interference  iu  these  cases  will  be  referred  to  in  the 
chapter  on  Treatment. 

Suppurative  cholecystitis  and  cholelithiasis  following  typhoid  fever 
are  conditions  requiring  surgical  treatment,  and  further  consideration  is 
not  possible  here. 

The  relation  of  typhoid-bacilli  to  the  formation  of  gall-Stones  is  an 
exceedingly  interesting  one.  Richardson  ^  has  shown  that  the  bacilli 
are  frequently  clumped  in  the  bile,  and  he,  Gushing,-  and  others  believe 
that  these  clumps  form  the  nuclei  for  stones.  From  the  interior  of 
stones  the  typhoid-bacilli  have  been  isolated  in  a  number  of  instances, 
and  the  experimental  production  of  gall-stones  by  inoculation  of  typhoid- 
bacilli  into  the  gall-bladder  of  animals  has  been  successfully  accom- 
plished by  Gilbert  and  Fournier,''  Richardson,^  Gushing,'^  and  others. 

It  has  been  demonstrated  that  typhoid-bacilli  may  remain  Aiablc  in 
the  gall-bladder  for  years.  Hunner  ^  has  reported  a  case  of  suppurative 
cholecystitis  occurring  eighteen  years  after  the  attack  of  tj^phoid  fever, 
from  the  pus  of  w'hich  the  typhoid-bacillus  -svas  isolated  in  pure  culture. 

Reference  has  been  made  in  the  anatomic  section  to  the  condition  of 

^  Jour.  Bo.tton  Soc.  Mer/.  Scl.,  vol.  iii.  ^  Johns  Hopkinf;  Hasp.  Bid/.,  vol.  x. 

3  Compt.  rend,  de  la  soc.  bioL,  Oct.  30,  1897.  *  Loc.  cit.  ^  Loc.  cit. 

"  Johns  Hopkins  Hosp.  Bull.,  vol.  x. 


SYMPTOMS  AND    COMPLWATJONS.  211 

the  bile  itself.  This  is  known  to  be  thinner,  lighter  in  color,  and  of 
lower  specific  gravity  (from  1010  to  1010,  as  compared  with  the  normal, 
1026  to  1030,  Brouardel).  With  regard  to  the  influence  of  this  altera- 
tion upon  the  intestinal  contents  and  the  urine,  nothing  of  a  definite  nature 
is  known.  Possibly  the  striking  pallor  or  even  the  almost  complete 
decolorization  of  the  stools,  of  considerable  duration,  as  I  have  observed, 
may  be  dependent  upon  that  condition.  The  intimate  connection 
between  urobilinuria  ^  occurring  in  cases  <jf  typhoid  fever,  which  has,  as 
yet,  been  but  little  studied,  and  the  alterations  in  the  bile  and  the 
functions  of  the  liver  in  general,  is  a  matter  for  future  investigation. 
Symptoms  Referable  to  the  Intestinal  Tract. — The  inex- 
perienc«d  observer  is  likely  to  assume  an  intimate  relation,  and,  even  as 
to  details,  an  actual  parallelism,  between  the  conspicuous  specific  altera- 
tions in  the  intestine  and  the  clinical  manifestations..  This  may  be 
correct  with  regard  to  certain  less  common  or  subordinate  conditions. 
As  to  the  severity,  the  extent,  and  the  localization  of  the  usual  typhoid 
lesion  of  the  intestine,  however,  most  good  observers,  I  believe,  agree 
that  the  stages  of  the  disease  probably  correspond  in  general  with  the 
occurrence  and  the  development  of  the  lesion,  but  that  this  is  by  no  means 
true  of  the  character  of  the  manifestations,  the  severity  and  the  diu'ation 
of  the  abdominal  symptoms  in  detail.  Every  experienced  physician  will 
recall  walking  cases  of  typhoid  fever,  with  slight  general  symptoms, 
without  meteorism,  without  abdominal  pain,  and  without  diarrhea,  thai 
terminated  fatally  from  unexpected  intestinal  hemorrhage  or  perforative 
peritonitis,  and  occasioned  surprise  on  anatomic  examination  on  account 
of  the  unusual  extent  and  severity  of  the  typhoid  intestinal  lesions.  Con- 
versely, profuse  diarrhea  and  other  intestinal  symptoms  are  not  rare  in 
the  earliest  stages,  when  the  specific  intestinal  lesion  has  scarcely  beoun 
to  develop.  Every  experienced  physician  will  know  of  cases  presenting 
predominant  intestinal  symptoms  throughout  which  are  in  remarkable 
contrast  with  the  slight  anatomic  lesions  found  at  autopsy. 

I  shall  never  forget  a  case  seen  in  consultation.  A  young  woman  died 
at  the  beginning  of  the  third  week  of  an  attack  of  typhoid  fever.  She  had 
not  been  compelled  to  go  to  bed  until  five  days  before  death,  and  a?  late  as 
a  week  previously  had  spent  considerable  time  at  an  evening  entertainment 
without  special  inconvenience.  During  the  three  weeks  precedins:  death 
there  had  been  only  variable,  generally  diminished,  appetite  and  no  diarrhea, 
but  rather  constipation.  Marked  febrile  manifestations  had  been  noted  only 
during  the  last  six  days.  Post-mortem  examination  disclosed  intestinal 
typhoid  lesions  throughout  an  extent  that  I  have  rarely  since  observed.  In 
the  lower  two-thirds  of  the  ileum  almost  all  of  Peyer's  patches  were  infil- 
trated in  part  confluent,  and  in  the  stage  of  exfoliation  of  the  sloughs  ;  while 
1  Tissier,  T/iese,  Paris,  1890. 


212  TYPHOID  FEVER. 

in  the  region  of  the  ileocecal  valve  and  the  cecum  itself  there  was  scarcely 
a  free  area  of  mucous  membrane,  and  the  upper  third  of  the  large  intes- 
tine was  also  densely  occupied  by  lenticular  ulcers,  in  part  of  unusual 
size.  IStill  more  surprising  w^re  the  results  of  an  autoj)sy  on  the  wife  of  a 
physician,  who  apparently  had  died,  in  the  opinion  of  the  husband,  in  conse- 
quence of  perforation  of  an  ulcer  of  the  stomach  without  previous  noteworthy 
symptoms.  In  this  case  also  the  lesions  of  typhoid  fever  in  the  stage  of 
exfoliation  of  the  sloughs  were  found,  likewise  with  extension  of  the  intes- 
tinal lesion  from  the  valve  up  to  the  middle  of  the  ileum.  Death  had 
resulted  from  perforation  of  the  vermiform  appendix. 

It  will  be  seen,  therefore,  that  it  is  better  to  study  each  case  indi- 
vidually aud  to  reserve  a  decisiou  tbau  to  proceed  upon  schematic 
lines. 

^ye  shall  begin  the  discussion  of  the  individual  intestinal  manifes- 
tations with  meteorism.  Many,  particularly  older,  works  contain 
descriptions  of  the  early  onset,  of  the  severity  and  the  frequency,  and 
even  the  constancy  of  this  symptom,  such  as  no  longer  correspond  with 
the  experience  of  the  objective  observer  of  the  present  day.  On  the  con- 
trary, I  would  assert  that  considerable  meteorism  occurring  early  scarcely 
belongs  among  the  manifestations  of  a  well-marked  attack  of  typhoid 
fever  ])ursuing  a  regular  course.  It  is,  in  general,  apart  from  local 
and  special  conditions,  the  less  common  the  earlier  the  patient  comes 
under  observation  and  the  greater  the  care  given  him.  Under  favor- 
able conditions  in  private  practice  or  in  a  well-conducted  hospital,  the 
milder  and  moderately  severe  cases,  if  received  early,  are  likely  to  be 
unattended  ^\\i\\  meteorism,  or  at  most  to  exhibit  it  in  slight  degree. 
More  marked  meteorism,  if  it  develops  in  spite  of  good  care  and 
restricted  diet,  is  a  most  ominous  manifestation.  It  is  indicative  of  the 
extreme  severity  of  the  course  of  the  disease,  and  is  dependent  far  less 
upon  the  intensity  of  the  typhoid  intestinal  lesion  than  upon  the  intensity 
of  the  general  infection  which  gives  rise  to  paralysis  of  the  muscular  layer 
of  the  intestine,  and  thereby  to  gaseous  distention.  In  further  support 
of  this  view,  it  may  be  mentioned  that  severe  intestinal  manifestations, 
even  rather  persistent  diarrhea,  by  no  means  always  precede  or  accom- 
pany the  meteorism  ;  and  also,  conversely,  obstinate  constipation  is  by 
no  means  always  associated  with  it.  It  generally  appears,  on  the 
contrary,  to  be  a  sequel  of  the  meteorism. 

The  individual  portions  of  the  intestine  are  involved  in  the  gaseous 
distention  in  varied  degree.  As  has  been  mentioned,  the  large  intestine, 
and  especiallv  the  transverse  colon,  is,  as  a  rule,  involved  in  most 
marked  degree  and  most  frequently.  The  small  intestine  is  likely  to  be 
distended  less  markedly  in  comparison  with  the  colon,  often  remark- 


SYMPTOMS  AND   (JOMPLKJATIONS.  213 

ably  little.  Decided  meteorism,  if  it  involve  the  small  intestine  at 
all,  is  located  with  prefercsnce  in  those  parts  that  are,  as  a  rule,  less 
attacked  by  medullary  infiltration,  namely,  the  region  of  the  jejunum 
and  the  upper  portions  of  the  ileum.  Under  such  circumstances  the 
transverse  colon,  unless  displaced  or  exhibiting  abnormal  arrangement 
of  its  coils,  may  be  seen  beneath  the  abdominal  walls,  in  the  form  of 
step-like  loops  passing  transversely  above  and  below  the  umbilicus. 

In  addition  to  the  general  there  are  not  rarely  severe  local  disturb- 
ances that  give  rise  to  the  meteorism,  and  that  are  the  more  readily 
overlooked  in  the  soporose  patient,  inasmuch  as  he  does  not  by  com- 
plaint suggest  thorough  local  examination.  In  this  category  belong 
especially  circumscribed  peritonitis  and  intestinal  hemorrhage,  the  latter 
of  which  is  by  no  means  always  indicated  at  once  by  the  evacuation  of 
bloody  stools.  Incarceration  of  the  bowel,  volvulus  or  intussusception, 
which,  it  is  true,  occur  rarely,  must  also  be  thought  of.  In  a  nrnnber 
of  instances  I  have  observed  marked  meteorism  and  symptoms  of  ileus 
in  direct  association  with  typhoid  perityphlitis. 

If,  therefore,  marked  meteorism  appears  generally  as  a  sequel  or 
associated  phenomenon  of  other  serious  conditions,  it  is  by  no  means 
thereby  implied  that  on  its  own  account  it  may  not  exert  injurious 
effects,  especially  by  diminishing  the  capacity  of  the  thorax  and  so 
interfering  with  the  respiration,  already  so  gravely  threatened  by  the 
typhoidal  disease  of  the  respiratory  organs.  Abdominal  tenderness,  spon- 
taneous or  on  palpation,  is  rarely  present  under  ordinaiy  conditions.  In 
uncomplicated  cases  the  patients  complain,  if  at  all,  of  scarcely  more 
than  a  sense  of  tension  and  pressure.  Only  in  the  presence  of  meteor- 
ism of  marked  degree,  even  if  not  of  inflammatory  nature,  will 
palpation  often  be  attended  with  pain.  Far  more  common  than 
general  tenderness  of  the  abdomen  is  tenderness  in  the  right  iliac  fossa, 
which  is  referable  to  the  portion  of  intestine  preferably  the  seat  of  the 
ulcerative  process.  In  some  cases  this  tenderness  is  constantly  some- 
what higher  toward  the  liver,  and  this  is  possibly  due  to  the  congenital 
dislocation  of  the  cecum  upward  (Curschmann),  which  is  known  to 
occur  not  at  all  rarely.  McCrae  has  carefully  studied  500  cases  of 
typhoid  fever  at  the  Johns  Hopkins  Hospital  with  reference  to  abdom- 
inal pain  and  tenderness.  He  found  that  about  two-fifths  of  the  patients 
are  free  from  pain  or  tenderness,  rather  less  than  one-fifth  have  tender- 
ness only.  Pain  due  to  some  condition  other  than  the  specific  bowel- 
lesions  was  present  in  about  14  per  cent,  of  the  cases.  It  occurred  with 
hemorrhage  or  perforation  in  about  5  per  cent,  of  all  cases.  It  was 
most  constantly  present  with  perforation,  when  it  was  usually  sudden  in 


214  TYPHOID  FEVER. 

ouset,  severe  in  character,  and  ])aroxysmal  in  dccnrrence.  In  about 
two-tit'ths  of  all  ciises  with  pain  no  canse  coukl  be  ibiuid. 

In  connection  with  the  question  as  to  Avhether  there  is  pain  associated 
with  an  inflamed  serous  surface  over  an  inflamed  Pcyer's  patch,  he  quotes 
an  interesting  case  in  which  the  severe  pain,  associated  with  other  symp- 
toms, led  to  a  diagnosis  of  some  acute  abdominal  complication,  and  an 
exploration  was  done  midcr  local  cocain  anesthesia.  Just  under  the 
point  where  the  })atient  had  complained  of  greatest  jiain  was  a  large 
Pcyer's  patch  with  the  serosa  much  inflamed.  With  the  handling  of 
the  intestine  he  made  no  complaint  of  pain,  but  even  a  gentle  touch 
over  this  inflamed  area  made  him  cry  out.  Yet  in  other  cases  patients 
made  no  complaint  when  the  serous  surface  over  the  ulcers  was  handled. 
It  is  questionable  whether  deep  ulceration  may  be  a  cause  of  pain. 

Since  the  time  of  Chorael,  clinicians  attach  no  little  importance 
to  the  occurrence  of  gurgling  and  splashing,  which  it  is  said  can 
almost  constantly  be  induced  by  palpation  of  the  cecal  region  in  cases 
of  typhoid  fever — the  gargouillement  of  the  French.  As  to  the 
occurrence  of  this  phenomenon,  and  its  striking  frequency  in  cases 
of  typhoid  fever,  there  can  be  no  doubt ;  but  I  would  call  attention 
to  the  fact  that  it  should  not — as  is  often  the  custom — be  considered  an 
important  symptom  of  the  disease.  In  my  experience  the  phenomenon 
is  so  inconstant  that  I  am  not  in  the  habit  of  attaching  important  diag- 
nostic significance  either  to  its  absence  or  its  presence.  From  the  theoretic 
point  of  view  also  this  inconstancy  could  scarcely  be  otherwise,  for  the 
development  and  the  distribution  of  the  specific  typhoid  intestinal  lesions 
are  so  variable,  as  has  been  pointed  out  in  the  anatomic  section,  that  the 
anatomic  conditions  in  the  lower  portion  of  the  ileum  and  the  cecum 
that  render  the  development  of  that  symptom  physically  possible  are 
not  fulfilled  with  any  regularity. 

Finally,  it  may  be  mentioned,  with  reference  to  palpation  of  the 
abdomen,  that  care  should  be  taken  to  avoid  confusing  circumscribed 
tenderness  of  the  abdominal  walls  that  may  be  associated  with  various 
changes  in  the  abdominal  muscles,  such  as  lacerations,  hematomata,  etc., 
which  are  known  to  occur  so  frequently,  with  local  inflammatory  proc- 
esses in  the  internal  abdominal  organs.  I  have  observed  the  commis- 
sion of  such  an  error  in  a  number  of  instances. 

The  Stools. — It  is  customary  to  speak  of  a  "  typhoid  stool,"  and 
this  designation  is  employed  to  describe  a  peculiar,  and  therefore  diag- 
nostically  important,  characteristic  of  the  intestinal  discharges.  Un- 
doubtedly the  discharges  which  are  spoken  of  as  typhoid  stools  ]:)resent 
a  peculiar    appearance.     Apart,   however,  from    the  demonstration  of 


SYMPTOMS  AND   COMPLKJATIONS.  215 

typhoid-bacilli,  neither  their  physical  nor  their  chemic  condition  presents 
anything  specific.  Their  diagnostic  value  resides  especially  in  their 
association  with  a  number  of  other  symptoms.  It  is  well  known  that 
the  so-called  typhoid  stools  are  thin,  liquid,  (jf  ochre-yellow  color,  "  pea- 
soup-like."  They  exhibit  an  alkaline  reaction,  and  they  possess  at 
times,  although  by  no  means  always,  a  peculiar  ammoniacal  odor.  Both 
of  these  characteristics  are  attributed  by  Parkes  and  Lehmann  to  the 
presence  of  ammonium  carbonate  and  a  fixed  alkali.  It  is  characteristic 
for  the  stools,  when  permitted  to  stand,  to  separate  soon  into  two  layers, 
a  lower,  yellowish-gray,  friable,  flocculent,  opaque  one,  and  an  over- 
lying, watery,  turbid,  translucent  one  that  contains  remarkably  little 
(only  about  4  per  cent.)  of  solid  matter  and  is  particularly  deficient  in 
albumin  and  mucus.  It  is  evidently  this  deficiency  of  the  fluid  in 
mucus  that  renders  it  incapable  of  being  emulsified  and  that  favors  the 
separation  of  the  typhoid  stools  into  layers. 

Microscopic  examination  of  the  sediment  of  the  stool  discloses 
structures  derived  from  the  food,  more  or  less  altered  intestinal  epithe- 
lium, detritus,  and  smaller  and  larger  particles  of  slough,  and  in 
the  second  and  third  weeks  even  larger  shreds  derived  from  exfoliation 
of  the  sloughs.  In  addition,  white  and  red  blood-corpuscles  are  always 
present  in  small  number,  and  also  masses  of  various  micro-organ- 
isms. So  long  ago  as  the  year  1834,  Sch5nlein  showed  that  in  addi- 
tion to  all  these,  quantities  of  triple  phosphates  are  almost  constantly 
present.  Although  his  opinion  that  these  are  specific  constituents  of 
the  typhoid  stool  has  not  been  confirmed,  they  are,  nevertheless, 
undoubtedly  more  common  in  association  with  typhoid  fever  than  with 
other  diseases,  and,  therefore,  are  not  without  diagnostic  significance. 
Concerning  the  presence  of  typhoid-bacilli  in  the  stools,  detailed  state- 
ments have  already  been  made  in  the  chapter  on  Etiology.  Their  bearing 
upon  diagnosis  can  be  estimated  from  that  section. 

It  must  be  emphasized  that  the  stools  just  described  are  by  no  means 
so  constant  or  so  frequent  as  the  inexperienced  might  believe,  and  that 
when  the  disease  is  accompanied  by  any  diarrhea,  the  stools  are,  in 
general,  not  likely  to  be  exceedingly  numerous,  particularly  not  so  fre- 
quent as  in  the  majority  of  cases  of  acute  intestinal  diseases,  dysentery, 
catarrh,  and  allied  conditions.  From  three  to  six  thin  stools  in  twenty- 
four  hours  may  be  considered  as  the  average  number  in  the  diarrhea 
of  typhoid  fever.  A  larger  number,  up  to  twelve,  is  less  commonly 
observed,  and  then  only  for  a  short  time.  Abnormal  frequency  of 
intestinal  evacuations,  when  continued  for  a  considerable  length  of  time, 
justifies  a  fear  that  the  disease  will  pursue  a  severe  course — in  this 


216  TYPlIOin  FEVER. 

connection  my  own  experience  is  entirt'ly  in  lu-cord  \\\t\\  that  of 
Louis,  Murcbison,  Trousseau,  and  others.  In  the  absence  of  h)cal 
disease  at  the  anus,  such  as  hemorrhoids,  fissures,  etc.,  the  intestinal 
discbarges  of  t^-pboid  patients  are  almost  always  imattended  with 
pain  or  tenesmus. 

The  time  of  the  first  appearance  and  the  duration  of  the  diarrhea 
exhibit  wide  variations.  Not  rarely  thin  stools  occur  as  early  as  the 
prodromal  stage,  before  the  onset  of  the  fever.  They  are  often  incor- 
rectly attributed  to  simple  intestinal  catarrh,  and  occasionally  also 
to  the  excessive  and  protracted  action  of  laxatives,  wliich  had  been 
administered  to  overcome  existing  constipation.  At  this  time  the  dis- 
charges do  not  so  readily  form  layers,  and  also  are  often  dark  in  color, 
resembling  ordinary  tharrheal  stools,  thereby  increasing  the  difficulty  in 
diagnosis.  This  appearance  may  be  due  to  the  fact  that  the  alterations 
in  the  secretion  of  bile,  particularly  the  thinning  and  the  lighter  color 
of  the  secretion,  which  occur  so  constantly  at  the  height  of  the  disease, 
have  not  yet  begun.  This  prodromal  diarrhea  may  disappear  with  the 
beginning  of  the  fever  or  after  the  first  few  days  of  fever,  not  to  recur 
throughout  the  entire  course  of  the  disease  ;  or  followed  for  a  few  days 
by  constipation,  less  commonly  by  normal  evacuations,  after  which,  at 
the  end  of  the  first  or  the  beginning  of  the  second  week,  the  stools  again 
become  thin,  and  now  present  the  characteristic  pea-soup-lilvc  appear- 
ance. In  some  cases  stools  of  this  character  persist  throughout  the 
entire  febrile  period,  rarely  beyond  this,  with  approximately  the  same 
or  varying  frequency.  In  other  instances  diarrhea  alternates  with  con- 
stipation or  with  normal  discharges,  or  it  disappears  permanently.  The 
patients  then  generally  remain  more  or  less  constipated,  or,  what  is 
much  less  common,  the  intestinal  discharges  occur  regularly. 

If  an  exact  statement  is  desired  as  to  the  frequency  with  which  diar- 
rhea occurs  in  cases  of  typhoid  fever,  it  may  be  said  that  diarrhea 
throughout  the  whole  or  the  larger  part  of  the  febrile  period  of  the  dis- 
ease is  likely  to  occur  in  scarcely  one-third  of  all  the  cases,  while  in 
about  an  equally  large  number  diarrhea  occurs  but  transiently  or  in 
alternation  with  solid  discharges.  Of  3835  cases  that  I  have  exam- 
ined with  regard  to  this  point,  1289  belonged  to  the  first,  and  1359 
to  the  second  category,  while  1187  w^ere  throughout  free  from  diarrhea. 
These  cases  of  typhoid  fever  "  without  typhoid  stools  "  deserve  especial 
consideration  from  the  diagnostic  standpoint.  The  novice  is  far  too 
readily  disposed  under  such  conditions  to  doubt  the  existence  of  the 
disease.  The  experienced  physician,  however,  may  go  still  fiirther,  and 
maintain  that  of  this  lar^e  number  of  cases  without  thin  stools  more 


SYMPTOMS  AND   COMPLICATIONS.  217 

than  half  actually  suffer  from  coustipation,  frequently  throughout  the 
whole  course  of  the  disease,  less   commonly  for  a  short  time. 

The  following  figures  will  illustrate  these  relations  more  accurately  ;  and 
in  this  connection  it  may  be  mentioned  that  the  Leipsic  statistics,  which 
include  all  the  cases  observed  at  the  medical  clinic  during  thirteen  years, 
more  nearly  approximate  the  general  prevalent  conditions  than  the  Ham- 
burg statistics,  which  cover  a  single  epidemic.  Like  many  other  clinical 
manifestations  of  typhoid  fever,  the  variations  in  the  intestinal  discharges 
also  exhibit  not  inconsiderable  local  and  temporal  differences.  Neverthe- 
less, a  comparison  of  these  figures  discloses  on  the  whole  considerable  agree- 
ment. Of  2240  cases  during  the  Hamburg  epidemic  of  1887  that  were 
investigated  as  to  the  state  of  the  stools,  diarrhea  was  present  throughout  in 
809 — 36.1  per  cent. ;  the  stools  were  normal  throughout  in  116 — 5.2  per 
cent.  ;  constipation  was  present  throughout  in  567 — 25.3  per  cent.  ;  normal 
stools  alternated  with  constipation  in  52 — 2.3  per  cent.  ;  transitory  diarrhea 
alternated  with  normal  stools  in  202 — 9  per  cent.  ;  transitory  diarrhea 
alternated  with  constipation  in  424 — 18.9  per  cent. ;  diarrhea  alternated 
with  constipation  and  normal  stools  in   39 — 1.8  per  cent. 

Of  1875  cases  observed  at  the  Leipsic  medical  clinic  between  the  years 
1880  and  1893,  which  were  investigated  from  the  same  point  of  view,^ 
there  was  found  diarrhea  throughout  in  480 — 25.6  per  cent.  ;  normal  stools 
throughout  in  83 — 4.4  per  cent.  ;  constipation  throughout  in  307 — 16.4  per 
cent.  ;  normal  stools  in  alternation  with  constipation  in  62 — 3.3  per  cent. ; 
diarrhea  in  alternation  with  normal  stools  in  144 — 7.7  per  cent.  ;  diarrhea 
in  alternation  with  constipation  in  550 — 29.3  per  cent. 

Bloody  Stools. — The  hemorrhagic  discharges  which  are  here 
especially  referred  to  are  those  that  take  place  from  portions  of  intestine 
the  seat  of  the  specific  lesions,  and  therefore  stand  in  direct  relation 
with  the  typhoid  process.  Care  should  be  taken  to  avoid  confusing 
these  with  the  accidental  admixtures  of  blood  from  the  lower  portions 
of  the  rectum  or  the  anal  region,  due  to  hemorrhoids,  fissures,  and  the 
like,  which  not  rarely  greatly  agitate  the  layman  and  may  occasionally 
lead  the  physician  into  error.  Under  these  conditions  the  blood  gener- 
ally presents  a  fresh  appearance  or  is  found  in  coagulated  masses  or 
admixed  with  mucus ;  it  is  deposited  upon  or  lies  beside  the  fecal 
matter,  and  is  never  intimately  admixed  with  it. 

True  intestinal  hemorrhage  is  one  of  the  most  important  events  in 
the  entire  course  of  an  attack  of  typhoid  fever.  The  amount  varies 
between  slight  admixture  of  blood,  often  distinguishable  with  difficultv, 
even  on  microscopic  examination,  and  the  most  profuse  hemorrhages, 
the  blood  being  discharged  from  the  bowel  in  liter-amounts  and  rapidly 
causing  death  by  loss  of  blood.  In  accordance  with  the  amount  and 
the  source  of  the  blood,  and  the  time  that  elapses  between  the  extrava- 
sation and  the  discharge  with  the  stool,  the  latter  will  present  a  variable 
*  Inaug.  Diss.,  Leipsic,  1893,  by  Berg. 


218  TYPHOID  FEVER. 

appearance.  If  there  be  but  slight  admixture  of  blood,  the  stool  is 
likely  to  be  yellowish-red  or  brownish-red  in  color.  If  a  comparatively 
large  amount  of  blood  is  gradually  extravasated  and  is  not  expelled  at 
once,  it  will  appear  as  a  liquid,  from  dark  brown  to  reddish  black  in 
color,  or  even  as  an  almost  wholly  black,  viscid,  tar-like  mass,  often 
with  a  greenish  tinge.  If  the  hemorrhage  takes  place  rapidlv  from  one 
or  several  large  vessels,  and  if  the  blood  is  soon  expelled  as  a  result  of 
accelerated  peristiiltic  movements,  the  stools  acquire  rather  the  character 
of  simple  coagulated  blood,  namely,  reddish-black  or  blood-red,  gener- 
ally coagulated,  masses,  or  not  rarely  dark  clumps  of  blood  in  a  liquid  stool. 
The  usual  time  for  the  occurrence  of  this  dreaded  accident  is  often 
stated  to  be  later  than  my  exjjerience  indicates.  Although  local,  tem- 
poral, and  individual  influences  may  be  operative  in  this  connection,  I 
believe  the  statement  is  justified  that  fidly  30  per  cent,  of  all  intestinal 
hemorrhages  occur  within  the  first  two  weeks  of  the  disease,  and  then, 
naturally,  the  more  frequently,  the  more  nearly  the  close  of  the  second 
week  is  approached.  I  have  even  noted  periods  (Hamburg  epidemic 
of  1887)  in  which  half  of  all  the  instances  of  hemorrhage  (44.8 
per  cent.)  were  observed  during  the  first  two  weeks  of  the  disease,  while 
24.4  per  cent,  were  seen  in  the  third,  and  13.4  per  cent,  in  the  fourth 
week.  My  experiences  at  Leipsic  confirm  these  statements,  and  they 
are  perhaps  even  more  striking.^ 

The  average  conditions  may  be  indicated  by  the  following  figures  :  In  148 
cases  of  intestinal  hemorrhage  (Hamburg,  1886-1887),  the  bleeding  occurred 
from  the  sixth  to  the  ninth  day  in  12,  from  the  tenth  to  the  twelfth  day  in 
23,  from  the  thirteenth  to  the  fifteenth  day  in  23,  from  the  sixteenth  to  the 
eiffhteenth  day  in  31,  from  the  nineteenth  to  the  twenty-first  day  in  17,  from 
the  twenty-second  to  the  twenty-fourth  day  in  9,  from  the  twenty-fifth  to  the 
twenty-seventh  day  in  11,  from  the  twenty-eighth  to  the  thirtieth  day  in  10, 
from  "the  thirty-first  to  the  thirty-third  day  in  3,  from  the  thirty-fourth  to  the 
thirty-sixth  day  in  4,  after  the  thirty-sixth  day  in  5. 

As  there  can  be  no  question  of  extensive  exfoliation  of  sloughs  and 
the  opening  of  large  vessels  before  the  end  of  the  second-  week,  these 
early  hemorrhages  must  have  some  other  source.  As  a  matter  of  fact, 
they  take  place,  as  anatomic  investigation  shows,  from  the  soft,  spongy, 
exceedingly  hyperemic  and  friable  tissue  of  Peyer's  patches,  which  is 
discolored  dark  red  to  black,  and  which  may  undergo  this  serious 
alteration  as  early  as  the  beginning  or  the  middle  of  the  second  week, 
in  some  instances  even  earlier.  From  this  source,  if  numerous  Peyer's 
patches  are  involved,  the  hemorrhage  may  be  as  copious  as  from  eroded 
large  vessels. 

1  See  Berg,  Loc.  cit.,  p.  18. 


SYMPTOMS  AND   COMrLICATIONS.  219 

After  the  end  of  the  second  and  the  beginning  of  the  third  week  the 
hemorrhages  are  naturally  no  longer  due  to  these  alterations,  but  to 
exfoliation  of  the  sloughs  from  the  affected  Peyer's  patches  and  solitary 
follicles.  Depending  upon  the  seat  of  the  infiltration  and  the  depth 
attained  by  it,  one  or  more  smaller  or  larger  vessels  are  simultaneously 
eroded.  Inasmuch  as  the  process  of  infiltration  and  ulceration  of  the 
lymphatic  intestinal  apparatus — as  anatomic  observation  shows — does 
not  take  place  at  a  single  stroke,  but  rather  slowly,  in  stages,  so  also 
is  the  period  in  which  hemorrhage  is  dependent  upon  it  often  quite  long. 
Even  at  the  time  when  all  the  ulcers  may  be  thought  to  be  clean, 
or  in  greatly  reduced  individuals  many  weeks  after  this  period, 
hemorrhages,  sometimes  of  fatal  degree,  may  yet  occur.  These  result 
from  imperfectly  thrombosed  vessels  in  the  floor  of  ulcers,  often  also, 
even  when  the  intestinal  lesions  in  general  appear  to  be  healed,  from 
isolated  slugglish  ulcers,  situated  both  in  the  small  intestine  and  also 
relatively  quite  frequently  in  the  large  intestine.  This  intestinal  hemor- 
rhage may  be  observed  to  occur  as  late  as  between  the  thirtieth  and 
the  fortieth  day  of  the  disease,  and  even  still  later ;  I  have  observed 
it  on  the  fifty-second,  fifty-fifth,  and  fifty-eighth  days,  respectively. 

Hemorrhages  appear  to  be  much  less  common  during  relapses  than 
during  primary  attacks  of  the  disease.  Of  153  cases  of  hemorrhage 
that  I  have  analyzed,  this  complication  occurred  in  only  4  during 
relapses. 

The  number  of  bloody  stools  that  occur  in  the  individual  case  is,  as 
a  rule,  overestimated,  as  it  is  usually  stated  from  memory.  In  general, 
there  may  be  from  1  to,  at  most,  4,  which  usually  are  expelled  in  suc- 
cession at  relatively  short  intervals.  Much  more  rarely  I  have  observed 
a  larger  number  of  bloody  stools,  from  6  to  10,  and  only  in  isolated 
instances  more — up  to  20.  In  the  latter  cases  conditions  of  the  so- 
called  hemorrhagic  diathesis  are  probably  generally  present. 

Of  256. cases  of  intestinal  hemorrhage  observed  at  Leipsic  and  Hamburg 
that  I  analyzed,  from  1  to  4  bloody  stools  occurred  in  225,  and  a  larger 
number  in  only  31  ;  but  of  this  latter  number  the  cases  with  1  and  2  stools 
preponderated.  There  occurred  1  bloody  stool  in  78  cases,  2  bloody  stools 
in  57  cases,  3  bloody  stools  in  45  cases,  and  4  bloody  stools  in  45  cases. 

With  regard  to  age  and  sex,  the  mature  period  of  life  is  distinctly  that 
at  which  intestinal  hemorrhage  most  frequently  occurs.  It  is  much  less 
common  in  children,  and  this  statement,  agreeing  with  that  of  Henoch 
and  Rilliet  and  Barthez,  as  against  opposite  statements  by  a  number 
of  other  observers,  I  can  confirm  positively  upon  the  basis  of  a  large 
number  of  cases.     While  in  adults  I  have  at  certain  times  observed 


220  TYPHOID  FEVER. 

intestinal  hemoiThage  in  as  high  as  10  and  even  14  per  cent,  ui'  all 
patients,  I  have  noted  it  in  seaively  1  per  cent,  in  children.  Doubt- 
less this  circumstance  is  related  to  the  usually  lesser  extent  and  in- 
tensity of  the  typhoid  intiltration  of  the  intestine  in  childhood.  I 
have  been  unable  to  note  any  material  diiference  between  the  two  sexes 
with  reference  to  the  frequency  of  hemorrhage.  With  regard,  however, 
to  the  severity  and  the  danger  of  this  symptom,  men  appear  distinctly 
to  present  the  graver  condition. 

In  adults,  in  my  experience,  the  frequency  of  hemorrhage  is  quite  limited 
up  to  tlie  thirtieth  year  of  life,  although  greater  than  in  children.  After 
the  thirtieth  year  there  is  a  noteworthy  increase.  The  maximum  is  reached 
between  the  forty-lifth  and  the  fiftieth  year,  although  later  life  also  is  still 
exposed  to  risk.  During  some  epidemics,  it  is  true,  exceptions  to  this  rule 
appear  to  occur.  Thus,  in  Hamburg  iu  1887  young  persons  suffered  from 
intestinal  hemorrhage  with  relative  frequency,  as  the  following  figures 
show:  From  tifteeu  to  twenty  years,  27.7  per  cent.;  twenty -one  to  twenty- 
five  years,  25.3  per  cent.  ;  twenty-six  to  thirty  years,  21.7  per  cent.  ;  thirty- 
one  to  thirty-five  years,  10.8  per  cent.  ;  thirty-six  to  forty  years,  4.8  per 
cent. ;  forty-one  to  forty -five  years,  5.4  per  cent.  ;  forty -six  to  fifty  years, 

1.2  per  cent.  ;  fifty-one  to  fifty -five  years,  1.2  per  cent.  ;  fifty-six  to  sixty 
years,  1.2  per  cent. 

On  the  other  hand,  the  year  1886  exhibited  the  following  conditions: 
From  fifteen  to  twenty  years,  3.4  per  cent.  ;  twenty-one  to  twenty-five  years, 
4.9  per  cent.  ;  twenty -six  to  thirty  years,  4.9  per  cent.  ;  thirty-one  to  thirty- 
five  years,  7.1  per  cent.  ;  thirty -six  to  forty  years,  14  per  cent.  ;  forty-one 
to  forty-five  years,  7.7  per  cent.  ;  forty-six  to  fifty  years,  2  per  cent. 

The  frequency  of  hemorrhage  in  relation  to  the  number  of  cases  is 
variously  stated  by  different  obsem^ers.  Naturally,  it  makes  a  material 
difference  whether  one  considers  only  large  and  copious  hemorrhages  or 
includes  even  the  slightest  admixture  of  blood.  This  circumstance  may 
explain  some  extremely  low  as  well  as  some  extremely  high  estimates. 
Above  ail,  it  should  be  emphasized  that  the  frequency  of  hemorrhage 
varies  greatly  in  different  places  and  at  different  times.  In  my  expe- 
rience, if  those  cases  showing  only  a  trace  are  not  included,  and  the 
mean  of  many  years'  experience  in  different  places  is  taken,  the  average 
frequency  of  intestinal  hemorrhage  is  from  4  to  6  per  cent. 

In  Leipsic,  among  1626  cases  of  typhoid  fever  occurring  in  the  course  of 
thirteen  years,  I  noted  103 — 6.3  per  cent. — in  which  hemorrhage  occurred. 
Among  the  much  larger  number  of  cases  at  Hamburg,  hemorrhage  occurred 
in  4.6  per  cent,  in  1886,  and  in  3.8  per  cent,  in  1887.  These  figures  agree 
with  those  of  Griessinger,  who,  among  600  cases  of  typhoid  fever,  observed 
hemorrhage  in  5.3  per  cent.  Homolle  collected  the  enormous  number  of 
10,000  cases  of  typhoid  fever  from  various  sources  (including,  amojig  others, 
Louis,  Barth,  Eagaine,  De  Ceronville,  Griessinger,  Lieliermeister,  Golddam- 
mer,  Jessen,  Chvostek),  and  found  intestinal  hemorrhage  to  have  occurred  in 
4.65  per  cent.     Liebermeister  places  the  figure   relatively   high,   namely, 

7.3  per  cent.     The  statement  that  has  found  its  way  into  many  books,  that 


SYMPTOMS  AND   COMPLICATIONS.  221 

Murchison  had  observed  intestinal  hemorrhage  in  16.6  per  cent,  of  cases, 
is  based  upon  a  misconception.  The  figures  do  not  refer  to  patients  at  all. 
Murchison  observed  14  among  84  deatlis  as  a  result  of  heinorrliage — 16.6 
per  cent.  The  figures  given  in  the  reports  of  the  Wieden  Hospital  for 
the  years  1855-1857,  namely,  2  per  cent.,  are  remarkably  low.  Of  829 
cases  in  the  Johns  Hopkins  Hospital,  hemorrhage  occurred  in  6  per  cent. 

Among  the  exciting  causes  for  intestinal  hemorrhage,  dietetic  error, 
restlessness  on  the  part  of  the  patient,  especially  getting  up  too  early, 
may  be  mentioned  as  the  most  frequent.  These  factors  also  certainly 
explain  the  fact  that,  in  my  experience,  ambulatory  typhoid  frequently 
manifests  itself  by  unexpected  intestinal  hemorrhage.  The  treatment 
of  typhoid  fever  with  cold  baths  may  possibly  intensify  intestinal  hem- 
orrhage that  has  already  occurred.  It  is,  however,  j^robably  incapa- 
ble of  directly  exciting  the  hemorrhage.  During  the  period  in  which 
I  still  practised  frequent  and  cold  bathing  I  did  not,  on  the  whole, 
observe  hemorrhage  with  greater  frequency  than  since  I  have  employed 
bathing  less  frequently,  less  cold,  and  with  more  regard  to  the  indi- 
vidual case.  Although  Liebermeister  observed  hemorrhage  in  8.4  per 
cent,  of  cases  before  the  introduction  of  hydrotherapy,  and  after  its 
introduction  in  only  6.2  per  cent.,  the  reduction  being,  according  to 
him,  due  mainly  to  the  use  of  hydrotherapy,  I  would  point  out  that  in 
Hamburg,  with  almost  purely  expectant  treatment,  at  any  rate  M'itli 
only  the  infrequent  employment  of  baths,  we  observed  hemorrhage  in 
but  3.8  per  cent,  of  cases. 

With  regard  to  the  clinical  manifestations  of  intestinal  hemorrhage, 
it  may  be  stated  that  its  onset  is  rarely  announced  in  advance  in  any 
special  manner.  On  the  contrary,  the  hemorrhage  often  occurs — "  like 
a  flash  of  lightning  in  a  clear  sky  " — at  a  time  when  the  patient  feels 
entirely  well,  and  the  friends  are  most  hopeful.  Abdominal  pain  rarely 
precedes  the  hemorrhage.  Only  now  and  agam  have  I  observed  severe 
colic  and  peristaltic  unrest  of  the  intestines  for  from  one  to  several  days 
before  the  onset  of  the  hemorrhage,  but  I  am  inclined  to  attribute  these 
symptoms  rather  to  the  ultimate  (exciting)  cause  of  the  hemorrhage 
than  to  the  latter  itself. 

McCrae,^  in  his  analysis  of  500  cases  of  typhoid  fever  Tvnth  reference 
to  abdominal  pain,  found  that  pain  was  present  in  14  of  the  36  cases 
in  which  hemorrhage  occurred.  Its  importance  is  especiallv  in  reference 
to  the  differential  diagnosis  between  this  complication  and  perforation 
of  the  bowel.  The  frequency  with  which  both  complications  occur 
simultaneously  may  be  seen  from  the  fact  that  of  30  cases  of  perforation 
in  the  Johns  Hopkins  Hospital,  6  were  accompanied  by  hemorrhage. 

1  Iioc.  cii. 


222 


TYPHOID  FEVER. 


In  a  doubtful  case,  with  pain,  the  blood-examination  may  show  a 
marked  drojj  in  hemoglobin  and  number  of  red  corpuscles  before  any 
blood  appears  externally.  Thayer  ^  has  found  that  hemorrhage  from 
the  bowels  may  be  followed  by  an  increase  in  the  number  of  leukocytes, 
reaching  its  maximum  inside  of  twenty -four  hours.  In  some  cases, 
liowever,  the  hemorrhage  has  no  effect  on  the  number  of  leukocytes 
in   the  peripheral   circulation. 

In  cases  in  ^\"hicll  the  patients  are  not  already  greatly  reduced  in  conse- 
quence of  antecedent  disaise  or  of  the  special  severity  and  long  duration  of 
the  attack  of  typhoid  fever,  slight  or  even  moderately  severe  hemorrhages 
in  small  number  cause  no  material  alteration  in  the  ceneral  condition. 

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Profuse  hemorrhage,  however,  is  under  all  conditions  a  serious  occurrence, 
to  Avhich  the  patient  may  succumb,  in  the  course  of  a  few  hours,  amid 
symptoms  of  most  profound  acute  anemia.  Fortunately,  such  a  course 
is  exceptional.  In  order  that  the  patient  should  finally  die  as  a  result 
of  hemorrhage,  its  repeated  occurrence  is  necessary.  The  cases  are 
especially  pathetic  in  which  it  has  been  possible  to  sustain  the  patient 
in  s])ite  of  copious  loss  of  blood,  but  who  nevertheless  dies  after  the 
lapse  of  a  few  days  in  consequence  of  unexpectedly  recurring  and,  at 
times,  not  even  profuse  hemorrhage.  Such  cases  are  at  the  same  time 
strons:  evidence  of  the  e-reat  decree  to  which  the  resistance  of  the 
t}'phoid  patient  is  reduced  in  consequence  of  profuse  loss  of  blood. 

^  Loc.  cit. 


SYMPTOMS  AND   COM  PLICATIONS.  223 

In  those  cases  in  which  the  patient  does  not  die  during  the  first  copious 
hemorrhage,  the  clinical  picture  becomes  alarmingly  altered.  The  skin 
acquires  a  waxy  pallor,  there  is  relaxation  of  the  features,  the  pulse 
becomes  small  and  shows  greatly  increased  frequency,  lividity  and  cold- 
ness of  the  extremities,  and  possibly  syncope,  appear.  With  the  rapid 
increase  in  pulse-frequency  there  is  generally  associated  a  rapid  reduc- 
tion in  the  body.-temperature.  The  curve  may  be  observed  to  decline 
from  40°  or  41°  C.  far  below  the  normal — to  35°  C.  and  below — in  the 
course  of  a  few  hours.  This  characteristic  intersection  of  pulse-  and 
temperature-curves,  of  which  an  illustration  is  given,  is  of  grave 
prognosis  (Fig.   24). 

Depending  upon  the  constitutional  condition  and  the  impression  that 
the  disease  has  already  made  upon  the  organism,  even  slight  hemorrhage 
may  be  attended  with  more  or  less  marked  depression  of  the  body-tem- 
perature. The  temperature-curve  of  the  typhoid  patient  reacts  in  a 
remarkably  sensitive  maimer  to  hemorrhage  in  far  greater  degree  than 
the  pulse,  which,  in  the  presence  of  moderate  intestinal  hemorrhage,  by 
no  means  always  becomes  smaller  and  more  frequent,  in  correspondence 
with  the  reduction  in  temperature.  I  have  often  observed  the  pulse 
but  little  influenced  with  reference  to  fulness,  tension,  and  frequency 
when  the  hemorrhage  was  not  repeated  or  was  but  small  in  amount. 
Quite  rarely  I  have  even  seen  the  pulse-frequency  fall  parallel  with  the 
temperature-curve — a  condition  that  is,  without  doubt,  to  be  considered 
as  a  favorable  prognostic  sign. 

It  is  an  interesting  and  practical  fact  that  even  with  the  occurrence 
of  profuse  intestinal  hemorrhage  the  extravasation  and  the  evacuation 
of  the  blood  externally  by  no  means  always  take  place  in  immediate 
succession.  On  the  contrary,  it  more  often  happens  that  cases  are 
observed  in  which  the  patient  becomes  profoundly  anemic  and  emaciated, 
while  the  temperature  rapidly  declines  and  the  pulse  becomes  smaller 
and  more  frequent — signs,  therefore,  of  considerable  internal  hemor- 
rhage are  present — and,  nevertheless,  hours  or  even  days  may  elapse 
before  the  resulting  bloody  intestinal  discharge  takes  place.  This 
appears  to  occur  especially  when  the  bleeding-point  is  situated  high  up 
in  the  bowel  and  the  extravasation  takes  place  slowly,  particularly  when 
the  blood  oozes  from  spongy  Peyer's  patches  which  are  in  a  state 
of  hemorrhagic  infiltration.  This  condition  is  also  favored  by  feeble- 
ness of  intestinal  peristalsis,  such  as  occurs  in  the  course  of  severe 
attacks,  particularly  if  several  considerable  hemorrhages  have  already 
taken  place.  Patients  dying  from  intestinal  hemorrhage  quite  gener- 
ally do  not  expel  the  last  portion  of  blood  extravasated.      Under  such 


224  TYPHOID  FEVER. 

circumstances  the  affected  portion  of  intestine  is  found  after  death  tilled 
with  a  tarry  mass,  which  often  is  of  viscid  consistency.  During  life  this 
condition  not  rarely  o-iyes  rise  to  corresjxindino-  physical  signs,  namely, 
increased  distention  of  the  abdomen,  witii  impairment  of  the  percussion- 
resonance  at  all  points,  or  even  extensive  dulness,  together  with  diminu- 
tion in  the  elastic  tension  of  the  abdomen  to  the  point  of  doughy 
consistency,  a  peculiar  tremulous  sensation  being  sometimes  imparted 
to  the  palpating  hand. 

The  occurrence  of  intestinal  hemorrhage  is  always  an  important  and 
serious  event.  If  the  patient's  strength  be  good  and  the  other  con- 
ditions favorable  after  the  tirst  hemorrhage,  the  physician  may  give  only 
a  doubtful  prognosis.  Fulminant,  rapidly  fatal  cases  are,  fortunately, 
not  common.  Nevertheless,  I  have  in  a  number  of  instances  seen 
death  occur  in  less  than  six  hours  after  the  first  hemorrhage,  and  twice 
even  during  the  first  hour.  A  fatal  termination  in  the  course  of 
tAvo  or  three  days  is  not  rare,  after  repetition  of  the  hemorrhage.  In 
general,  death,  when  it  occurs  at  all,  takes  place  in  the  course  of  from 
three  to  five  days.  In  some  cases  death  occurs  in  the  course  of  a  week 
or  two  weeks,  or  even  several  weeks,  after  the  hemorrhage  has  ceased. 
In  such  cases  examination  of  the  body  after  death  may  also  reveal 
nothing  special,  and  the  impression  is  gained  that  the  patients  have  not 
died  directly  from  the  hemorrhage,  but  from  the  attendant  loss  of 
strength,  from  which  they  were  unable  to  recover,  in  spite  of  the 
observance  of  all  possible  care. 

The  mortality  from  intestinal  hemorrhage  is,  in  general,  quite  high. 
On  the  average,  from  20  to  30  per  cent,  of  those  attacked  die. 
Griessinger  placed  the  figure  at  31.2  per  cent.,  Liebermeister  at  38.6 
per  cent.,  and  Homolle,  as  a  result  of  his  collective  investigation,  which, 
it  is  true,  is  unfavorably  influenced  by  the  inclusion  of  a  number  of 
small  groups  of  cases,  made  it  as  high  as  44.3  per  cent.  My  own 
analyses  show  38.2  per  cent,  for  Leipsic.  In  Hamburg  I  encountered 
remarkably  low  figures,  namely,  in  the  year  1886,  20.9  per  cent. ;  in 
the  year  1887,  only  11.6  per  cent.  These  figures  confirm  the  observa- 
tions of  all  physicians  that  not  only  the  frequency,  but  also  the  danger, 
of  intestinal  hemorrhage  may  vary  considerably  from  as  yet  unknown 
causes,  as  a  result  of  temporal  and  local  influences. 

Whether  sex  has  any  influence  on  the  prognosis  of  intestinal  hemor- 
rhage does  not  appear  as  yet  to  be  definitely  determined.  In  my  experi- 
ence the  danger  is  greater  in  men  than  in  women.  From  the  character 
of  the  bloody  stools — apart,  naturally,  from  the  absolute  amount  of 
blood — a  prognostic  guide  can  rarely  be  obtained.      I  should,  however. 


SYMPTOMS  AND   COMPLICATIONS.  225 

consider  the  discharge  of  blood  in  large  coagulated  masses  as  serious. 
This  can  be  considered  as  indicative  of  erosion  of  a  large  vessel,  and . 
probably  also  that  the  origin  of  the  hemorrhage  is  in  the  lower  portion 
of  the  intestine,  particularly  the  colon,  from  which  a  hemorrhage  is 
often  likely  to  be  especially  massive. 

The  view  taken  by  a  number  of  distinguished  clinicians,  such  as 
Graves,^  Trousseau,^  and  others,  that  intestinal  hemorrhage  is  not  a 
serious,  but,  on  the  contrary,  a  rather  favorable  occurrence,  is  most 
remarkable.  While  Graves  based  his  opinion  upon  concrete  instances, 
the  ingenious  Trousseau  was  led  to  a  generalization  of  this  view.  It 
cannot  be  denied  that  moderate  loss  of  blood,  or  even  a  single  consider- 
able intestinal  hemorrhage  which  is  not  repeated,  occurring  in  a  robust, 
full-blooded  patient  with  high  fever,  appears  at  times  to  influence  the 
general  condition  favorably.  The  patient  then  becomes  brighter,  the 
temperature  declines,  while  the  pulse  remains  good.  Even  the  spleen 
undergoes  distinct  reduction  in  size  (Eichhorst,  Curschmann),  and  if 
the  occurrence  takes  place  in  the  terminal  stage  of  the  disease,  convales- 
cence may  at  once  set  in.  As  opposed  to  such  rare  exceptions  is  the 
overwhelming  preponderance  of  unfavorable  results,  so  that,  even  from 
the  most  favorable  aspect,  the  occurrence  of  hemorrhage  cannot  be 
looked  upon  as  a  desirable  event.  It  should  here  again  be  pointed  out, 
and  cannot  be  too  strongly  emphasized,  that  even  distinguished  writers 
often  base  their  conclusions  upon  insufficient  statistics.  I  have  noted 
periods  in  which  only  2  of  50  successive  cases  of  intestinal  hemorrhage 
under  observation  terminated  fatally. 

Peritonitis  is  one  of  the  untoward  occurrences  in  the  course  of 
typhoid  fever  deserving  of  detailed  consideration.  It  may  remain  cir- 
cumscribed or,  as  is  unfortunately  more  common,  it  may  be  general. 
In  the  large  majority  of  cases  both  varieties  occur  as  sequels  of  the 
intestinal  lesion.  It  is  the  contamination  of  the  peritoneum  from  the 
intestinal  ulcers  by  the  exciting  agents  of  inflammation  or  the  escape 
of  intestinal  contents  into  the  abdominal  cavity  that,  in  accordance 
with  special  conditions,  gives  rise  at  times  to  circumscribed  foci  of 
inflammation,  and  at  other  times  to  general  peritonitis. 

The  inflammation  of  the  peritoneiun  is  but  rarely  independent  of 
the  specific  lesions  of  Peyer's  patches  and  the  solitary  follicles.  Now 
and  again  gangrene  of  the  bowel  from  some  other  cause  may  be  the 
underlying  factor.  Thus,  in  one  instance,  I  noted  such  a  condition  to 
be  caused  by  thrombosis  of  the  artery  supplying  that  portion  of  the 

^  Clinical  Lectures^  1848,  vol.  i. 

2  Clin,  med.,  2d  ed.,  transl.  by  Kunzmann,  vol.  i..  p.  238. 
15 


226  TYPHOID  FEVEB. 

bowel  and  of  the  accompanying  veins.  Perfi  )rati<in  of  other  organs  also 
may  be  the  cause  of  peritonitis,  as,  for  instance,  rupture  of  tlie  spleen 
or  of  the  mesenteric  glands  in  consequence  of  softening  or  abscess, 
rupture  of  the  gall-bladder,  of  the  larger  biliary  passages,  or  of  an 
abscess  of  the  liver  which  has  developed  in  the  course  of  the  attack 
of  typhoid  fever. 

The  (juestion  as  to  whether  a  localized  peritonitis  may  occur  without 
perforatiou  has  been  raised  by  Gushing,'  Avho  thinks  that  in  certain 
cases  the  earliest  symptoms  of  perforation  may  be  due  to  "  a  little  local- 
ized inflammation  of  the  serosa,  with  or  without  tbe  passage  of  micro- 
organisms, and  leading  to  a  slight  adhesive  peritonitis."  This  he 
speaks  of  as  the  pre-perforative  stage  of  ulceration.  He  mentions  a 
case  of  Murphy's  ^  in  which  there  was  peritonitis,  but  no  perforation 
found ;  and  also  5  cases  of  Gairdner's,^  in  which  fatal  peritonitis  oc- 
curred without  an  absolutely  complete  perforation.  Two  of  the  cases 
reported  by  Shattuck,  Warren,  and  Gobb  *  were  said  to  show  at  opera- 
tion "  a  general  septic  peritonitis,  originating  in  damaged  and  necrosed 
areas  of  peritoneum  over  the  bases  of  one  or  more  typhoid  ulcers." 

The  peritonitis  associated  with  the  specific  lesion  of  the  intestine  is 
not  only  one  of  the  most  frequent,  but  also  one  of  the  most  characteristic 
causes  of  a  sudden  dangerous  and  fatal  change  in  the  course  of  an 
attack  of  typhoid  fever.  There  are  very  few  other  acute  infectious 
diseases  in  Avhich  this  complication  occurs  at  all,  and  even  then  only 
as  a  rarity.  At  times  perforative  peritonitis,  like  intestinal  hemorrhage, 
is  the  first  distinctive  manifestation  in  a  case  of  ambulatory  typhoid 
fever  previously  showing  no  symptoms,  or  at  most  attended  with  obscure 
disturbances.  The  occurrence  is  not  at  all  rare,  so  that  if  individuals 
with  perforative  peritonitis,  giving  an  uncertain  history  or  none  at  all, 
are  admitted  to  a  hospital,  this  possibility  should  especially  be  kept  in 
mind. 

I  have  observed  cases  in  which  the  first  symptoms  of  peritonitis  occurred 
in  persons  who  had  been  previously  apparently  healthy  in  the  form  of  intes- 
tinal colic  or  sudden  collapse  while  walking  ahout  or  while  at  work.  A 
case  under  observation  was  brought  to  the  hospital  as  one  of  volvulus  ; 
another,  under  the  suspicion  of  having  attempted  suicide  with  arsenic ;  and 
a  third,  as  a  case  of  meat-poisoning. 

These  quite  surprising  and  often  unrecognized  cases  are  comparable 
with  those  in  which  the  symptoms  of  general  peritonitis  develop  sud- 

'^  Johns  Hopkins  Hosp.  Rep.,  vol.  viii. 

*  Keen,  Surgical  Coynplications  and  Sequels  of  Typhoid  Fever.^  Phila.,  1898,  p.  238. 
^  Glasgow  Med.  Joiir.,  vol.  xlvi.,  p.  114. 

*  Boston  Med.  and  Surg.  Jour.,  June  28. 


SYMPTOMS  AND   COMPLICATIONS.  227 

denly  in  a  case  of  typhoid  fever  of  apparently  mild  course,  with  moder- 
ate fever,  an  absence  of  meteorism,  and  with  other  very  mild  intestinal 
symptoms.  However  important  these  cases  may  be,  and  however  note- 
worthy from  jthe  diagnostic  point  of  view,  it  slxjuld  nevertheless  be 
noted  that  it  is  principally  the  severe  cases  and  those  that  pursue  a  grave 
course  from  the  outset  that  are  attended  with  perforative  peritonitis. 
Among  such  cases,  however,  it  is  by  no  means  only  in  those  attended 
with  severe,  persistent  diarrhea  that  perforative  peritonitis  occurs — a  fact 
which  confirms  the  general  statement  previously  made,  that  the  severity 
of  the  intestinal  manifestation  and  the  general  course  of  the  disease  are 
by  no  means  in  accord.  It  is  almost  exclusively  clinically  uncontrolla- 
ble and  anatomically  unfortunate  accidents  that  give  rise  to  ^perforation 
in  the  individual  case. 

That  perforation  is  more  likely,  however,  to  occur  in  cases  with 
diarrhea  is  shown  from  the  statistics  of  perforation  at  the  Johns  Hop- 
kins Hospital.  Of  30  cases  of  perforation,  20  had  diarrhea,  16  at  the 
time  of  perforation.  This  becomes  more  striking  when  it  is  known 
that  of  the  whole  number  of  cases  (829),  only  19  per  cent,  had  diarrhea 
during  the  course  of  the  disease. 

Generally,  there  is  but  a  single  point  through  which  the  intestinal 
contents  escape.  Now  and  then,  2  or  3  openings  close  together  may 
be  found ;  rarely,  2  widely  separated  points  of  rupture,  as,  for  instance, 
in  the  ileum  and  the  colon,  are  demonstrable.  I  have  observed  a 
larger  number  of  perforations  at  the  same  time  in  only  a  few  instances. 
The  maximum  numbers  were,  in  one  case,  10,  in  another  12,  and  in  a 
third  15  perforations.  Hoffmann  refers  to  an  autopsy  in  which  25 
perforations  were  found. 

As  the  perforation  is  almost  exclusively  confined  to  the  specific 
lesions  of  Peyer's  patches  and  the  solitary  follicles,  its  frequency,  with 
regard  to  situation,  likewise  corresponds  with  that  of  these  alterations 
in  the  individual  portions  of  the  bowel.  Perforation,  accordingly,  is 
most  frequent  in  the  lower  portions  of  the  ileum,  especially  in  the 
vicinity  of  the  cecum.  Rupture  of  the  bowel  at  a  higher  level  than 
the  lower  third  of  the  ileum  is  observed  less  commonly.  In  a  number 
of  instances,  it  is  true,  I  have  encountered  perforation  in  the  upper 
portions  of  the  ileum,  but  I  cannot  recall  an  instance  of  perforation  of 
the  jejunum,  such  as  has  been  described  by  Hoffmann.  The  cecum,  the 
parts  adjacent  to  the  valve,  and  the  vermiform  appendix  are  somewhat 
less  commonly  than  the  lower  portion  of  the  ileum,  but  still  frequently 
enough,  the  seat  of  rupture.  I  have  observed  perforation  of  the  colon 
at  almost  all  parts,  even  down  to  the  descending  colon  and  the  sigmoid 


228  TYPHOID  FEVER. 

flexure ;  perforation  has  been  noted  even  in  the  reetnm  by  various 
Avriters,  and  I  have  likewise  t)bserved  it.  The  ascending  and  the 
transverse  colon,  however,  appear  to  be  the  favored  seats  of  the  lesion. 

AVith  regaixl  to  time,  the  occurrence  of  perforation  coincides  espe- 
cially with  the  period  of  exfoliation  of  the  sloughs.  Its  earlier  occur- 
rence, as  is  so  frequently  the  case  with  hemorrhage,  is  extremely  rare, 
and  results  only  under  exceptional  conditions.  The  princii)al  time  for 
the  occurrence  of  perforation  of  the  bowel  is  therefore  the  end  of  the 
second  and  the  third  week  of  the  disease.  Anatomic  investigation 
teaches  that  the  accident  occurs  especially  when  the  medullary  infiltra- 
tion is  most  extensive,  and  extends  down  to  the  peritoneimi,  or  even 
involves  this  also.  In  this  way  the  floor  of  the  ulcer  may  come  to  be 
formed  by  a  translucent  membrane  as  thin  as  paper,  that  will  be  unable 
to  withstand  even  the  slightest  mechanical  influences.  In  some  cases 
the  iutiltration  and  the  sloughing  are  so  deep  that  the  peritoneum  also 
is  involved,  and  ruptm-e  ensues  immediately  upon  the  occurrence  of 
sloughing.  In  the  cases  just  referred  to,  in  which,  after  clearing  up 
of  the  idcers,  a  greatly  thinned  area  in  the  intestinal  wall  remains,  per- 
foration tiikes  place  either  through  rupture  or  through  more  or  less 
gradual  extension  of  the  ulcerative  process.  The  latter  00010*8  especially 
in  cases  in  which  the  peritonitis  develops  late — at  the  end  of  the  third 
or  in  the  fourth  week. 

The  character  of  the  resulting  opening  depends  partly  upon  the 
preliminary  alterations  and  the  mode  of  development  of  the  perforation. 
The  perforations  due  to  large  direct  loss  of  structure,  which  I  have 
seen  attain  a  diameter  of  from  a  quarter  of  an  inch  to  one  inch,  are 
generally  attributable  to  the  exfoliation  of  large  profound  sloughs.  The 
small  cribriform  openings,  at  times  lying  close  together  in  considerable 
number,  are  often  referable  to  slowly  progressive  ulceration,  while  rupt- 
lu-es  due  to  mechanical  influences  are  often  distinguished,  as  I  think  I 
have  been  able  to  show,  by  the  longitudinal,  slit-like,  ragged  character 
of  the  openings.  Among  the  mechanical  influences  giving  rise  to 
rupture  of  the  bowel  at  the  situations  anatomically  predisposed  is 
gaseous  distention  of  the  intestine,  especially  if  it  undergo  sudden  aug- 
mentation in  a  single  portion.  Further,  the  condition  is  certainly  often 
due  to  other  mechanical  influences,  especially  those  exerted  by  the  solid 
intestinal  contents.  That  still  other  mechanical  influences  acting  from 
within  and  without,  such  as  vomiting,  forced  movements,  especially 
too  early  sitting  up  or  getting  up,  violent  expulsive  efforts  and  strain- 
ing at  stool  and  in  micturition,  may  exert  an  injurious  effect,  can  be 
comprehended  theoretically,  and  the  possibility  of  their  exercising  such 


SYMPTOMS  AND   COMPLICATIONS.  229 

an  action  is,  unfortunately,  too  often  demonstrated  at  the  bedside. 
Dietetic  errors,  with  secondary  gastro-intestinal  catarrh  and  abnormally 
increased  peristalsis,  are  with  equal  propriety  to  be  held  responsible 
in  certain  cases.  All  these  points  cannot  be  too  clearly  kept  in  mind 
by  the  young  physician,  in  order  that  he  may  as  fiilly  as  possible  shield 
his  patients  from  injury  at  a  critical  period.  While  in  a  few  cases 
rupture  must  inevitably  take  place  in  consequence  of  the  extent  and  the 
depth  of  the  ulcerative  process,  in  the  overwhelming  majority  of  cases 
the  conditions  are  fortunately  such  that,  under  the  most  favorable  cir- 
cumstances, with  careful  observation  of  internal  and  external  precau- 
tions, even  deep  ulceration  may  undergo  cicatrization,  and  even  minute 
perforations  may  be  rendered  harmless  by  timely  adhesion  with  adja- 
cent organs.  It  is  a  particularly  disturbing  fact  that  perforation  may 
still  take  place  at  a  late  stage  of  the  disease,  after  the  usual  period 
when  exfoliation  of  the  slough  is  completed,  and  even  at  a  time  when 
the  patient  appears  almost  convalescent.  This  unfortunate  accident  at 
times  occurs  in  Peyer's  patches  and  solitary  follicles  which  exhibit  a 
recrudescence  of  the  specific  lesions  at  a  time  when  the  majority  of  the 
ulcers  are  in  process  of  healing  or  have  already  undergone  cicatriza- 
tion. In  other  cases  imperfectly  cicatrized  ulcerated  areas,  especially 
those  with  very  thin  floors,  may  subsequently  reopen  and  undergo  per- 
foration. Finally,  the  indefinitely  protracted  so-called  sluggish  ulcers 
may  be  a  source  of  great  danger.  I  have,  for  instance,  observed  per- 
forative peritonitis  develop  after  the  fiftieth  and  the  sixtieth  day  of  the 
disease,  in  one  instance  even  after  the  hundredth  day — a  warning  for 
patients  and  their  friends,  who  often  charge  the  physician  mth  pedantic 
rigidity  of  supervision  during  convalescence. 

Such  late  perforations  are  emphasized  also  by  other  writers,  namely, 
Louis,  Murchison,  Griessinger,  Niemeyer,  and  others.  Among  these,  Gries- 
singer  considers  the  sluggish  ulcers  as  especially  dangerous.  That  possi- 
bility of  perforation  exists  throughout  quite  a  long  time  is  shown  by  the 
following  figures : 

Of  73  cases  of  perforation  that  I  have  analyzed,  this  accident  occurred 
between  the  eleventh  and  the  twentieth  day  in  23,  from  the  twenty-first 
to  the  thirtieth  day  in  31,  from  the  thirty-first  to  the  fortieth  day  in  13,  and 
after  the  fortieth  day  in  6. 

The  frequency  of  perforation  of  the  bowel  may,  precisely  like  that 
of  intestinal  hemorrhage,  be  extremely  variable  at  different  times.  I 
have  observed  epidemics  in  which  the  condition  was  quite  rare,  and 
others  in  which  the  cases  were  exceedingly  common.  This  fact  probably 
explains  the  extreme  diversity  in  the  statements  of  various  writers. 
Upon  what  this  temporal  variation  in  frequency  depends  is  as   yet 


230  TYPHOID  FEVER. 

unknown.  The  degree  to  wliicli  the  number  of  cases  of  perforation 
may  at  times  increase  is  shown  by  an  analysis  by  Murchison,  who  noted 
perforation  in  21.2  per  cent,  among  16')  autopsies  in  cases  of  typhoid 
fever.  Although  Heschel  ^  observed  only  56  cases  of  perforative  peri- 
tonitis (4.4  per  cent.)  among  1271  autopsies  during  the  years  from 
1840  to  1849,  this  number  is  distinctly  less  than  that  usually  en- 
coimtered.  Brouardel  and  Thoinot,"  who  analyzed  1721  autopsies 
from  English,  French,  and  German  sources,  found  perforation  in  190 
cases — 11.03  per  cent.  Griessinger  noted  perforation  in  14 — 11.01 
per  cent. — of  118  autopsies  made  by  himself.  I  have  personally 
observed  93  cases — 16.17  per  cent. — among  575  autopsies  (Hamburg- 
Leipsic).  It  will  therefore  not  be  an  exaggeration  to  assume  that  in 
from  9  to  12  per  cent,  of  all  fatal  cases  of  typhoid  fever  death  results 
from  perforative  peritonitis. 

The  percentiige  of  deaths  due  to  perforation  in  the  Johns  Hopkins 
Hospital  during  the  past  ten  years  is  considerably  higher  than  this.  Of 
63  deaths,  20  (31.7  per  cent.)  were  due  to  perforation. 

Fortmiately,  the  absolute  frequency  of  perforation,  making  allowance 
for  temporal  and  individual  variations,  is  distinctly  less  than  that  of 
intestinal  hemorrhage.  I  believe  that  under  the  most  unfavorable  cir- 
cumstances perforation  occurs  in  not  more  than  3  per  cent,  of  all  cases 
of  typhoid  fever.  In  my  Leipsic  statistics  (1626  patients)  the  propor- 
tion was  2.2  per  cent.  In  Hamburg  it  was  1.6  per  cent,  among  4094 
patients.  The  estimate  of  Griessinger,  who  observed  perforation  in  14 
cases — 2.3  per  cent. — among  600  of  typhoid  fever,  is  in  agreement  with 
my  OAvn. 

Among  829  cases  of  typhoid  fever  in  the  Johns  Hopkins  Hospital, 
there  were  23  (2.7  per  cent.)  cases  of  perforation.  Twenty  of  these 
were  fatal,  and  3  recovered  following  operation. 

Age,  sex,  and  social  condition  do  not  occasion  such  marked  differ- 
ences with  reference  to  the  danger  of  perforation  as  some  observers, 
upon  the  basis  of  an  insufficient  number  of  cases,  state.  In  general  the 
conditions  are  analogous  to  those  in  connection  with  intestinal  hem- 
orrhage. I  believe  that  children,  especially  under  the  age  of  ten  years, 
are  less  commonly  attacked  than  adults,  and  I  base  my  opinion  both 
upon  a  rather  large  personal  experience  and  upon  the  statements  of 
Topin,  Rilliet  and  Barthez,  Rocher  and  Henoch.  The  probable  reason 
for  this  is  the  generally  slighter  intensity  of  the  intestinal  affection  in 
children,  which  has    already  been  mentioned   in  the  consideration  of 

'  Zeit.  d.  Gesellsch.  d.  Aerzte  z.   Wien.,  1853. 
'  Lajievre  typho'ide^  Paris,  1895,  p.  79. 


SYMPTOMS  AND   COMPLICATIONS.  231 

hemorrhage.  Among  adults,  those  between  eighteen  and  forty  years  of 
age  are  especially  predisposed  to  perforation.  After  the  fortieth  year  of 
life  the  occurrence  is  relatively  less  common.  The  contrary  opinion, 
occasionally  expressed,  that  later  life  is  in  turn  more  predisposed,  is 
not  in  accord  with  my  experience. 

In  general,  men  appear  to  be  attacked  by  perforation  more  fre- 
quently than  women.  This  is  by  no  means  dependent  upon  inequality 
in  the  development  of  the  specific  intestinal  lesions  in  the  two  sexes, 
but  probably  upon  the  fact  that,  with  equal  chances,  men  are  more 
unfavorably  influenced  during  convalescence  by  reason  of  previous 
derangement  of  the  digestive  apparatus,  due  to  diet  and  mode  of  life, 
than  are  women,  and  often  also  by  coming  under  treatment  late,  as  well 
as  by  greater  impatience  and  carelessness  during  convalescence. 

With  regard  to  social  position,  perforative  peritonitis  undoubtedly 
occurs  rather  more  frequently  among  the  poorer  classes,  probably  in 
consequence  of  the  less  favorable  conditions  of  living  and  of  nutrition 
among  these  classes,  and  also  on  account  of  the  less  efficient  nursing 
and  care  devoted  to  them.  This  is  in  accord  with  my  observation  that 
the  occurrence  of  perforation  is  more  frequent  among  ambulatory  and 
milder  cases    in  the  poorer  classes. 

Murchison  and  Griessinger  probably  emphasize  unduly  the  predominance 
of  perforation  in  the  male  sex.  I  have  noted  periods  in  which  this  differ- 
ence, which  I  appreciate,  was  not  present.  Thus,  in  the  year  1886-1887,  in 
Hamburg,  both  sexes  were  affected  almost  equally,  and  in  the  year  1887 
females  even  somewhat  more  frequently. 

Symptoms  of  Perforation. — The  complication  often  occurs 
quite  suddenly  and  unexpectedly,  without  previous  noteworthy  injurious 
influences.  At  times  it  is  preceded  by  more  or  less  ill-defined  disturb- 
ances, namely,  increased  abdominal  tension,  colicky  pain,  borborygmi, 
and  diarrhea.  Intestinal  hemorrhage  of  greater  or  less  amount  is  not 
rarely  an  indication  of  impending  breach  in  continuity.  That  this  is 
not  rare  is  shown  by  the  fact  that  of  30  cases  of  perforation  in  the 
Johns  Hopkins  Hospital,  6  have  been  preceded  or  accompanied  by 
hemorrhage.  The  time  when  perforation  occurs  is  at  times  quite 
definitely  stated  by  intelligent  patients.  They  complain  of  sudden 
stabbing  pain,  or  even  of  an  actual  sense  of  laceration. 

In  the  great  majority  of  cases  the  perforation  is  soon  followed  by 
abdominal  pain  of  rapidly  progressive  intensity,  which  can  be  recog- 
nized as  due  to  peritonitis  from  the  fact  that  it  is  greatly  increased 
on  breathing,  on  passive  and  active  movement,  and  on  pressure  and 
palpation    of  the   abdomen.     In    some   cases    the    patients    refer    the 


232  TYPHOID  FEVER. 

point  of  origin  of  the  ])ain  to  the  right  hypogastrium.  The  majority, 
however,  are  unable  to  <lesigmite  any  definite  situation.  Simultaneously 
with  the  onset  of  tlie  pain,  frequently  even  preceding  it,  there  occur 
distressing  retching  and  vomiting,  in  conseipienee  of  which  the  gastric 
contents,  which  are  more  or  less  markedly  changed,  and  often  contain 
the  iugesta  to  Avhich  the  accident  is  due,  are  evacuated.  Soon  only 
small  amounts  of  mucoid  bilious  matter  are  expelled  with  the  distress- 
ing retching. 

The  abdomen  now  becomes  progressively  more  distended,  at  times 
to  an  extreme  degree,  so  that  the  cutaneous  covering  of  the  abdomen 
appears  smooth  and  glistening.  The  markedly  elevated  position  of 
the  diaphragm  thereby  induced,  in  conjunction  with  the  peritonitic  pain, 
greatly  interferes  with  breathing.  The  bowels  are  generally  constipated 
from  the  outset  and  remain  so ;  also,  flatus  is  passed  less  frequently, 
if  at  all.  The  cause  of  these  disturbances,  the  paresis  of  the  muscular 
layer  of  the  intestine,  soon  attains  a  high  degree  of  intensity.  The 
vomiting  not  rarely  acquires  a  fecal  character,  so  that  the  entire  condi- 
tion suggests  the  existence  of  ileus,  and  for  which  it  may  indeed  be 
mistaken  by  those  of  limited  experience.  Although  the  symptoms 
described  are  generally  attributed  to  the  peritonitis  alone,  at  times, 
especially  when  the  jieritonitic  process  originates  in  the  vicinity  of 
the  ileocecal  valve  and  the  lowermost  portion  of  the  ileum,  and  is 
particularly  localized  in  this  situation,  there  may  be  actual  occlusion  of 
the  lumen  of  the  bowel,  and  thus  true  ileus. 

The  general  condition  of  the  patient  changes  approximately  in  cor- 
respondence with  the  local  manifestations.  The  features  become  drawn, 
the  nose  pointed,  the  extremities  livid  and  cold,  and  the  face  and  the 
body  are  often  covered  with  cold  sweat.  The  condition  of  the  pulse 
soon  becomes  poor,  so  soon  that  at  times  it  may  be  the  first  indication 
of  the  grave  significance  of  abdominal  pain  of  sudden  onset.  The 
pulse  becomes  frequent,  iiTcgular,  and  small ;  then  thready,  scarcely  to 
be  counted,  and  frequently,  at  a  time  when  the  patient  is  still  conscious 
and  the  friends  are  still  hopeful,  is  no  longer  palpable  at  the  radial 
artery.  Wlien  perforation  with  general  peritonitis  is  present,  the 
body-temperature  rises,  as  a  rule,  but  little,  in  an  irregular  manner, 
or  not  at  all.  Only  toward  the  end  is  rapid  elevation  to  an  extreme 
degree  sometimes  observed.  Most  frequently  a  more  or  less  rapid,  often 
abrupt,  decline  of  temperatiu'e  to  far  below  the  normal  occurs,  and  per- 
sists until  death.  In  some  cases,  especially  those  with  subsequent 
elevation  of  temperature,  I  have  observed  a  chill  at  the  outset.  How 
this    is    brought    about    in    the   individual  case,  and  which    kind    of 


SYMPTOMS  AND   COMPLICATIONS.  233 

patients  exhibit  high,  and  which  low,  temperatures,  is  not  yet  wholly 
clear  to  me. 

In  the  severest  cases,  those  in  which  the  intestinal  contents,  poured 
out  of  large  openings,  soon  deluge  the  entire  abdominal  cavity,  the 
symptoms  described,  intensified  to  the  maximum,  occur  synchronously. 
Collapse  then  appears  to  develop  abruptly,  the  pulse  becomes  impercep- 
tible during  the  first  few  hours,  and  the  temperature  falls  below  the 
normal  with  equal  rapidity.  Often  the  abdomen  does  not  become 
distended,  and  the  peritonitic  pain  is  absent,  a  circumstance  that  greatly 
increases  the  difficulty  of  diagnosis  even  for  the  expert  clmician.  The 
majority  of  these  patients,  unfortunately,  retain  perfect  consciousness, 
some  until  immediately  before  death,  which  may  take  place  before  the 
termination  of  the  first  twenty-four  hours. 

When  the  course  of  the  peritonitis  is  less  rapid,  the  patients  may 
even  recover  somewhat  from  the  primary  shock,  the  pulse  may  again 
become  fuller  and  slower,  the  temperature  may  again  rise,  though 
rarely,  it  is  true,  as  has  been  mentioned,  to  any  considerable  height. 
Unfortunately,  the  hope  thus  aroused  is  almost  always  deceptive ;  only 
rarely  does  the  peritonitis  become  locally  circumscribed.  It  extends 
without  restraint,  and  the  local  and  general  symptoms  increase  accord- 
ingly, until  death  occurs  in  profound  collapse  at  the  end  of  the  second 
or  the  third  or,  at  the  furthest,  on  the  fourth  day.  The  cases  of  severe 
onset  scarcely  ever  live  beyond  this  time. 

More  protracted  cases  may  occur  in  which,  in  consequence  of  the 
form  or  the  seat  of  the  perforation,  as,  for  instance,  when  there  is  a 
single  or  a  number  of  minute  cribriform  openings  close  together,  minimal 
amounts  of  intestinal  contents  may  slowly  escape,  and  temporary  adhe- 
sions prevent  the  diffusion  of  the  infectious  material  throughout  the 
entire  peritoneal  cavity.  Under  such  circumstances,  rapid  progress  and 
complete  cessation  may  alternate.  It  is  in  such  cases,  also,  that,  in 
addition  to  the  general  peritonitis,  one  or  several  partly  encapsulated 
foci  of  pus  are  found  in  the  right  iliac  fossa,  behind  the  liver,  in  the 
true  pelvis,  or  in  other  portions  of  the  abdominal  cavity.  Patients  pre- 
senting such  conditions  may  live  for  six  or  eight  days.  I  have  person- 
ally seen  a  few  cases  in  which  death  occurred  on  the  ninth  or  the  tenth, 
even  on  the  eleventh,  day.  Those  are  horrible  days  for  friends  and 
physician,  with  alternation  between  fear  and  hope,  the  latter  being  finally 
almost  always  unrealized.  I  cannot  believe  in  spontaneous  recovery 
from  universal  perforative  peritonitis,  such  as  has  been  reported  by  a 
number  of  observers.  In  a  number  of  my  o^^ti  cases  terminating 
favorably  and  suggesting  this  possibility,  I  would  consider  them  rather 


234  TYPHOID  FEVER. 

as  cases  of  circumscribed,  although  at  times  quite  extensive,  peritonitic 
affections,  which  exhibited  especial  severity  of  the  initial  shock  on 
account  of  individual   causes. 

iBarly  Diagnosis  of  Perforation. — Consideriug  the  very  prom- 
ising results  that  have  been  obtained  from  operative  interference  in 
cases  of  perforation,  and  since  good  results  are  mainly  dependent  uj)()n 
early  recognition  of  the  condition,  it  is  extremely  desirable  that  the 
physician  .should  learn  to  recognize  the  symptoms  of  perforation,  par- 
ticularly of  its  onset,  apart  from  those  of  the  consecutive  peritonitis. 
Of  all  early  symptoms,  pain  is  the  most  constant  and  important. 
McCme  ^  has  most  carefully  studied  the  question  of  abdominal  pain  in 
typhoid  fever  with  special  reference  to  its  character  in  perforation. 
Perforation  occurred  in  13  of  his  cases,  and  in  all  of  them  pain  was 
present  and  seemed  severe.  In  10  of  these  cases  the  patients  had 
been  previously  quiet  and  comfortable,  and  were  suddenly  seized  with 
severe  abdominal  pain,  which  in  4  cases  was  severe  enough  to  make  the 
patient  cry  out.  In  the  remaining  3  cases  the  pain  was  present  for  some 
days  before  the  perforation  occurred.  '  In  14  cases  of  21  reported  by 
Shattuck,  Warren,  and  Cobb,^  "  there  was  early  warning  pain — earlier 
by  a  definite  number  of  hours  than  the  severe  symptoms."  It  may  be 
said  that  a  sudden  onset  of  pain  demands  the  most  careful  examination 
of  the  patient  and  careful  noting  of  every  symptom.  After  onset  the 
pain  is  usually  not  constantly  severe,  but  is  paroxysmal.  In  some 
cases  the  pain  may  be  present  for  several  hours  before  the  onset  of  ten- 
derness and  muscle-spasm.  In  many  cases,  however,  with  the  onset 
of  pain  there  is  tenderness,  usually  localized,  most  often  situated  in  the 
right  hypogastrium.  Associated  with  this  tenderness  there  is  usually 
some  rigidity  or  spasm  of  the  abdominal  muscles,  especially  of  the  right 
rectus,  and  limitation  of  the  abdominal  respiratory  movements.  These 
latter  signs,  Avhile  not  certain,  are  of  the  greatest  importance  when  taken 
in  connection  with  the  other  symptoms.  A  sudden  fall  of  body- 
temperature,  when  present,  is  a  very  characteristic  symptom,  but  its 
frequent  absence,  and  the  fact  that  it  occurs  frequently  in  other  condi- 
tions, such  as  hemorrhage,  make  it  an  unreliable  sign.  Vomiting  is  an 
important  symptom  when  present.  Increasing  distention,  as  shown  by 
the  gradual  rise  of  the  lower  line  of  hepatic  dulness,  which  should  be 
marked  out  at  short  intervals  in  suspicious  cases,  is  an  impoi-tant, 
though  usually  somewhat  later,  sign.  It  must  also  be  remembered  that 
the  Hippocratic  facies  is  not  only  a  late  occurrence,  but  that  the  pinched, 
drawn,  anxious  face  may  be  one  of  the  first  suggestive  signs  to  the 

1  Loc.  cit.  '^Boston  Med.  and  Surg.  Jour..,  June  28,  1900. 


SYMPTOMS  AND  COMPLICATIONS.  235 

experienced  observer.  Much  attention  has  been  given  t<j  the  question 
of  an  early  increase  in  the  number  of  the  leukocytes  in  the  peripheral  cir- 
culation following  perforation.  Many  more  observations  will  have  to 
be  made  before  an  absolutely  accurate  estimation  of  the  value  of  this  sign 
can  be  determined.  Thayer  ^  concludes,  from  a  study  of  this  question, 
that  perforation  of  the  bowel  is  usually  followed  by  an  increase  in  the 
number  of  the  leukocytes  in  the  peripheral  circulation.  This  increase 
may  be  considerable,  or  may  be  slight  and  appreciable  only  in  com- 
parison with  previous  counts  ;  hence  the  great  importance  of  frequent 
counts  of  the  leukocytes  during  the  course  of  the  fever.  Not  infre- 
quently, following  the  rise  there  is  a  fall ;  and  in  a  number  of  cases 
there  may  be  no  rise  at  all,  but  there  may  even  be  a  fall  from  the 
onset.  Conditions  such  as  these  are  indications  of  the  malignity  of  the 
infection  or  the  prostration  of  the  patient. 

Operative  Treatment. — To  Leyden  in  Germany  and  Wilson  in 
America  are  due  the  credit  of  first  ardently  advocating  operation  in 
cases  of  perforative  peritonitis.  The  American  surgeons  especially  took 
up  the  subject,  and  have  been  most  earnest  advocates  of  the  utility  of 
this  procedure  (Finney,^  Keen,^  Gushing  *).  In  1899,  Keen  was  able 
to  collect  from  the  literature  158  cases  of  operation  for  perforation  in 
typhoid  fever.  The  recovery-rate  in  the  entire  158  cases  is  23.41  per 
cent.  When  this  is  contrasted  with  the  recovery-rate  in  mioperated 
cases  (not  over  5  per  cent.),  the  value  of  the  procedure  is  evident.  Of 
16  cases  operated  upon  in  the  Johns  Hopkins  Hospital  during  the  past 
few  years  by  Finney,  Gushing,  and  Mitchell,  6  recovered — 37.5  per 
cent. 

That  operation,  when  performed  early,  especially  if  done  under  local 
cocain  anesthesia,  as  advocated  by  Gushing,^  is  in  itself  not  of  great 
danger  to  the  patient,  even  though  at  the  time  he  is  extremely  weak 
from  the  effects  of  the  disease,  has  been  shown  by  numerous  cases,  and 
especially  by  several  on  whom  exploratory  laparotomy  was  done  and 
no  perforation  found.  These  results  have  corroborated  the  statement 
of  Mikulicz,  made  in  1884  :  "  If  suspicious  of  a  perforation,  one  should 
not  wait  for  an  exact  diagnosis  and  for  peritonitis  to  reach  a  pronounced 
degree;  but,  on  the  contrary,  one  should  immediately  proceed  to  an 
exploratory  operation,  which,  in  any  case,  is  free  from  danger.'"' 

I  have  observed  spontaneous  recovery  from  perforative  peritonitis 

1  Johns  Hopkins  Hosp.  Rep.^  vol.  viii.  ^  Annals  of  Surgery,  March,  1897. 

3  Jour.  Am.  Med.  Assoc,  Jan.  20,  1900. 

*  Johns  Hopkins  Hosp.  Rep.,  vol.  viii.         °  Phila.  Med.  Jour.,  March  3,  1900. 
^  Quoted  by  Gushing,  loc.  cit. 


236  TYPHOID  FEVER. 

ouly  in  eases  iu  which  strong  protective  adhesions  and  encapsulation, 
formed  about  the  site  of  perforation,  separated  this  from  the  remaining 
larger  portion  of  the  peritoneal  sac.  tSuch  forms  of  circumscribed  peri- 
tonitis may  also  set  in  violently  with  profound  manifestations  of  shock, 
and,  especially  when  large  fecal  abscesses  are  present,  may  be  attended 
with  most  grave  synn)toms.  Recovery  may  follow  under  such  condi- 
tions as  a  result  of  timely  surgical  intervention,  or  of  spontaneous  i'U})t- 
ure  directly  outward,  or  into  the  intestine  or  other  hollow  viscus.  The 
prognosis  shoidd,  however,  at  best  be  dubious.     Many  of  such  cases  die. 

In  a  number  of  cases  I  have  observed  circumscribed  peritonitis 
develop  with  very  slight  local  and  general  symptoms,  and  i)rogress  quite 
slowly,  often  with  remarkably  little  pain,  and  with  remittent  or  even  inter- 
mittent fever.  Under  such  circumstances  the  conditions  present  con- 
sist principally  in  small  abscesses  encapsulated  between  adherent  coils 
of  intestine,  situated,  however,  in  jjarts  of  the  abdominal  cavity  accessible 
to  operative  intervention  only  with  exceeding  difficulty.  If,  under 
such  circumstances,  spontaneous  rupture  with  complete  evacuation  does 
not  take  place,  this  distressing  condition  may  drag  along  until  the 
patient  is  relieved  by  death  due  to  some  further  complication,  or  after 
months   of  suffering. 

An  interesting  position  among  the  various  forms  of  circumscribed 
peritonitis  is  occupied  by  the  cases  in  which  the  process  is  local- 
ized to  the  right  iliac  fossa,  and  especially  to  the  vicinity  of  the  cecum, 
cases  that  can  be  appropriately  designated  as  typhoid  perityphlitis  or 
paratyphlitis.  These  cases  occm:  more  frequently  than  is  generally  be- 
lieved, and  may  be  looked  upon  as  typical  processes,  since  they  originate 
from  portions  of  intestine  especially  involved  in  cases  of  typhoid  fever. 
That  in  such  cases  minute  openings  of  perforation,  or  even  extreme 
ulcerative  thinning  of  the  intestinal  wall  without  actual  perforation, 
may  permit  the  escape  of  the  inflammatory  irritants,  is  readily  com- 
prehensible in  accordance  with  previous  statements.  It  is  interesting 
to  note  that  the  site  of  the  lesions  in  question  corresponds  with  that 
of  the  usual  inflammation  of  the  cecum.  In  the  presence  of  ty]3hoid 
perityphlitis,  perforation  of  the  vermiform  appendix,  which,  it  is  well 
known,  is  quite  generally  involved  in  the  medullary  infiltration,  plays 
an  important  role.  Also,  in  the  cecum  itself,  especially  in  the  neighbor- 
hood of  the  valve,  as  well  as  at  the  junction  with  the  ascending  colon, 
I  have  in  a  number  of  instances  found  deep  ulcers  with  minute  perfo- 
rations to  be  the  cause  of  circumscribed  inflanunations  in  the  right  iliac 
fossa. 

I  have  observed  typhoid  perityphlitis  during  all  stages  when  peri- 


SYMPTOMS  AND   COMPLICATWNS.  237 

tonitis  is  likely  to  develop,  with  greater  relative  frequency,  however,  in 
the  later  stages  of  the  disease,  and  even  during  convalescence,  in  one 
instance  on  the  eighteenth,  and  in  another  on  the  twenty-first  afebrile 
day.  Chomel  and  Gonzonnec  ^  have  made  similar  observations.  The 
local  symptoms  are  like  those  of  ordinary  inflammatory  processes  in  the 
iliac  fossa,  namely,  painful  circumscribed  infiltration,  at  times  of  mode- 
rate extent,  at  other  times  more  extensive,  occasionally  quite  indurated  ; 
this,  it  appears  to  me,  more  readily  and  more  rapidly  terminates  in  an 
abscess  than  in  cases  other  than  typhoid.  Precisely  as  in  these  other 
cases,  the  affection  may  assume  the  characters  of  both  perityphlitis  and 
paratyphlitis,  or  of  a  combination  of  both.  In  one  instance  in  private 
practice  I  observed  the  development  of  a  retroperitoneal  abscess,  which 
was  successfully  evacuated  through  a  lumbar  incision. 

Typhoid  perityphlitis  is  not  alone  of  theoretic  interest,  but  it  is 
also  a  condition  of  practical  importance.  This  is  true  especially  from 
the  diagnostic  standpoint,  and  here,  above  all,  it  is  of  importance  when 
the  affection  occurs  in  association  with  slight,  ill-defined,  at  times 
protracted  cases  of  typhoid  fever,  or  in  the  course  of  an  attack  of 
ambulatory  typhoid  fever. 

Thus,  I  have  observed  cases  in  which,  during  residence  in  the  hospital 
following  a  period  of  general  malaise  of  from  twelve  to  fifteen  days'  duration 
or  longer,  with  irregular  fever,  unattended  with  diarrhea  and  roseolse,  but 
with  recent  enlargement  of  the  spleen,  perityphlitis  developed,  which  then  led 
to  a  correct  interpretation  of  the  condition.  In  other  cases  that  came  under 
observation  with  the  simple  diagnosis  of  perityphlitis,  the  history  of  a  general 
febrile  disease  having  preceded  the  local  inflammatory  process,  and  having 
lasted  sometimes  two  or  three  weeks,  first  aroused  suspicion  of  typhoid  peri- 
typhlitis, which  subsequently  was  verified  either  by  the  further  typical  course  of 
the  disease  or  by  the  occurrence  of  a  characteristic  relapse.  I  have  observed 
cases  of  typhoid  perityphlitis  in  Berlin  and  in  Hamburg  in  private  practice 
as  well  as  in  hospital  practice.  Unfortunately,  no  reference  is  made  to  this 
subject  in  the  statistics  of  Schultz.  Six  of  my  cases  from  the  Leipsic  clinic 
are  reported  in  the  dissertation  of  Glos  (1892).  Further,  Schoulein  ^  and 
Rokitansky  ^  mention  the  condition  in  question.  Griessinger  and  Chvostek 
also  were  aware  of  its  occurrence.  Recently,  it  has  been  mentioned  in  the 
dissertations  of  Langheld,  Schneller,  and  Holscher.*  Cases  of  typhoid  peri- 
typhlitis, such  as  have  been  described  by  Besnier  and  Follet,  belong  in  this 
category  symptomatically,  but  not  etiological ly.  These  were  cases  of  ordi- 
nary perityphlitis  pursuing  a  septic  course.  They  are  capable,  it  is  true,  of 
causing  great  difficulty  in  differential  diagnosis.  Thus,  I  can  recall  a  case 
under  my  observation  in  which,  during  the  course  of  the  disease,  intercurrent 
unilateral  parotitis  appeared  to  be  especially  indicative  of  typhoid  fever.  It 
subsequently  proved  to  be  a  septic  metastasis  from  a  purulent  focus  in  the 
iliac  fossa. 

^  These,  Paris,  1881.  ^  Kim.   Vorlesungen 

^  Lehrbuch  der  pathologischen  Anatomic.  *  Loc.  cit. 


238  TYPHOID   FEVER. 

Comparatively  little  is  to  be  said  concerning  the  cases  of  peritonitis 
in  connection  with  inflammation,  softening,  and  rupture  of  other  abdom- 
inal organs,  to  Avhich  consideration  has  already  been  given.  Some, 
particularly  those  due  to  rupture  of  the  spleen  and  tlie  mesenteric 
glands,  almost  always  escape  correct  clinical  interpretation.  The  rare 
instimces  of  perforation  of  the  large  biliary  passages  or  of  secondary 
abscess  of  the  liver  can  generally  only  be  suspected. 

ALTERATIONS   IN   THE   RESPIRATORY   ORGANS. 

Tiiese  are  among  the  most  frequent  and  the  most  varied  disorders  in 
the  course  of  typhoid  fever.  They  consist  in  part  of  actual  complica- 
tions and  sequels,  in  part  of  specific  alterations  dependent  upon  the 
bacillus  of  Eberth  and  its  ]>roducts.  A  sharp  differentiation  between 
the  two  sets  of  conditions  is  not,  as  yet,  possible ;  it  is,  however,  prob- 
able that  the  extensive  catarrhal  and  certain  inflammatory  alterations 
in  the  respiratory  organs  especially  belong  etiologically  in  the  second 
category. 

Alterations  in  the  Nose  and  the  Nasopharynx. — The  nose 
and  the  nasopharynx  quite  generally  exhibit  at  the  beginning  and  at 
the  height  of  the  disease  the  condition  of  so-called  dry  catarrh.  The 
mucous  membrane  of  the  nose  is  likely  to  be  reddened  and  spongy,  and 
it  frequently  exhibits  a  dark-red,  velvety  swelling,  especially  over  the 
turbinated  bone.  The  secretion  is,  under  such  conditions,  quite  mod- 
erate, and  the  orifice  and  anterior  portion  of  the  nasal  cavity  are  often 
covered  with  a  fuliginous  deposit.  If  the  nasal  cavity  be  very  nan'ow 
normally  or  in  consequence  of  congenital  or  acquired  change  in  shape, 
its  permeability  may  be  greatly  diminished,  with  resulting  pathologic 
mouth-breathing,  the  consequences  of  which  are  doubly  injurious  to  the 
t^'phoid  patient. 

From  the  symptomatologic  standpoint,  it  must  be  emphasized  that 
the  ordinaiy  symptoms  of  coryza — sneezing,  increased  secretion,  con- 
junctival catarrh — are  among  the  greatest  exceptions,  at  least  in 
moderately  severe  and  severe  cases  of  typhoid  fever,  and  may  be 
thrown  in  the  balance  against  a  diagnosis  of  typhoid  fever.  Severe 
infectious  conditions  with  a  predominating  coryza  generally  have  some 
other  significance.  ,  Under  such  circumstances  typhus  fever  and  influ- 
enza especially  would  have  to  be  considered. 

The  hyperemia  not  rarely  becomes  so  marked  that  even  on  merely 
blowing  the  nose  bloody  mucus  is  discharged,  or  small  amounts  of 
blood  gain  entrance  into  the  nasopharynx,  which,  when  expelled  in  the 
form  of  sanguinolent  sputum,  may  give  rise  to  unnecessary  alarm.    Quite 


SYMPTOMS  AND  COMPLICATIONS.  239 

frequently  the  fragility  of  the  blood-vessels  of  the  nasal  mucous  membrane 
is  so  marked  that  actual  profuse  epistaxis  occurs.  This  is  observed  by 
far  the  more  frequently  during  the  period  of  incubation  and  in  the 
beginning  of  the  febrile  stage.  I  believe  that  50  per  cent,  of  all  cases 
of  epistaxis  during  typhoid  fever  occur  at  this  time.  Nose-bleed  is  less 
frequent  at  the  beginning  of  the  second  week,  while  it  is  uncommon  at  the 
height  of  the  disease,  becoming  again  somewhat  more  frequent  during  the 
last  days  of  the  fever,  in  the  period  of  steep  curves,  and  during  convales- 
cence. Bleeding  from  the  nose  may  be  repeated  several  times  within 
a  short  period,  and  it  may  occasionally  be  so  profuse  that,  in  spite  oi 
apparent  amelioration  of  the  condition  of  the  patient  at  first,  it  may 
greatly  depress  him  ;  and  when  it  occurs  at  a  late  period  in  the  febrile 
stage  or  during  convalescence,  it  may  be  directly  a  source  of  danger. 

In  a  number  of  instances  I  have  observed  patients  under  such  conditioQS 
reduced  to  an  alarming  state  of  debility.  In  one  case  in  private  practice  I 
was  compelled  to  resort  to  subcutaneous  infusion  of  blood,  and  in  another  to 
introduce  saline  infusion  beneath  the  skin,  in  order  to  overcome  the  impending 
danger.  Liebermeister  has  observed  2  fatal  cases,  and  Striimpell  1.  Tam- 
ponade of  the  nose,  even  from  behind  with  Bellocq's  cannula,  is  not  at  all 
rarely  necessary. 

It  may  be  mentioned  further  that  nose-bleed  plays  a  not  unimpor- 
tant role  in  the  cases  of  hemorrhagic  typhoid  fever,  which,  fortunately, 
occur  but  rarely,  and  are  attended  with  such  a  grave  prognosis.  Apart 
from  these  hemorrhagic  cases,  which  may  occur  at  any  age,  young  per- 
sons are  particularly  likely  to  be  attacked  with  nose-bleed ;  children 
under  the  age  of  ten  years  less  commonly,  it  is  true,  than  older  ones. 
Epistaxis,  in  my  experience,  rarely  occurs  after  the  fortieth  or  forty-fifth 
year,  and  it  then  occurs  almost  solely  in  persons  presenting  other  pre- 
disposing conditions,  either  local  or  general,  as,  for  instance,  chronic 
alcoholism.  With  regard  to  the  frequency  of  epistaxis  in  general,  it 
may  be  stated  that  I  have  observed  it  in  6.5  per  cent,  of  1700  cases 
investigated  as  to  this  point — a  proportion  that  approximates  that  found 
by  Liebermeister  (7.5  per  cent.). 

Croupous  and  diphtheric  affections  of  the  nasal  mucous  membrane, 
which  are  rather  frequently  mentioned  in  older  writings,  I  have  observed 
with  extreme  rarity  m  cases  of  typhoid  fever.  When  present  at  all, 
they  occurred  almost  exclusively  in  association  Avith  similar  processes 
in  the  pharynx  and  upon  the  tonsils,  in  which  they  likewise  occur  but 
exceptionally. 

Larynx,  Trachea,  and  Bronchi.— If  these  structures  of 
patients  with  typhoid  fever  are  frequently  examined,  some  sponginess 


240  TYrUOW  FEVER. 

and  redness  of  the  mucous  membrane  will  nt)t  rarely  be  found  in  the 
region  of  the  false  vocal  bands  and  the  arytenoid  cartilages,  probably 
also  slight  discoloration  of  the  true  vocal  l)ands,  especially  at  their 
points  of  attachment,  and  rather  at  the  posterior  than  at  the  anterior 
portion.  The  laryngeal  mucous  membrane  also  presents  an  appearance 
of  dryness.  The  voice  of  the  patient  under  such  circumstances  is  weak, 
uncertain,  and  somewhat  hoarse.  More  i)ronouuced  catarrhal  laryngitis 
with  especially  marked  symptoms  is,  on  the  contrary,  not  frequent — in 
fact,  it  is  almost  as  rare  as  marked  corvza.  This  must  aarain  be 
emphasized  in  contrast  with  typhus  fever,  in  the  diagnosis  of  which 
nasal  and  laryngeal  catarrh  is  generally  of  importance. 

Of  great  importance,  on  the  other  hand,  in  cases  of  typhoid  fever, 
are  more  profound  affections  of  the  larynx,  ulceration  of  the  mucous 
membrane,  and  perichondritis.  The  occurrence,  seat,  form,  and  course 
of  these  conditions  are  so  ty]iical  that  the  question  arises,  Are  they, 
from  the  etiologic  standpoint,  a  part  of  the  typhoid  fever  itself? 
Although  little  is  as  yet  known  in  this  connection  from  the  bacterio- 
logic  standpoint,  an  affirmative  conclusion  with  regard  to  some  of  the 
alterations  is  most  probable  for  a  number  of  reasons.  As  is  known, 
there  have  been  demonstrated  (Cornil  and  Ranvier,  and  others)  in  cases 
of  typhoid  fever,  upon  the  posterior  wall  of  the  larynx,  between  the 
points  of  attachment  of  the  vocal  bands,  in  the  vicinity  of  the  arytenoid 
cartilages,  and  upon  the  epiglottis,  especially  at  its  base,  formations 
which  are  to  be  looked  upon  as  recently  infiltrated  lymph-follicles, 
comparable  with  similar  lesions  in  the  intestine  and  in  other  portions  of 
the  body.  As  previously  mentioned  (see  section  on  Pathology),  Schultz 
has  been  able  to  demonstrate  the  typhoid-bacilli  in  these  follicles  in  the 
larynx.  Like  the  follicles  in  the  intestine,  these  exhibit  a  marked 
tendency  to  undergo  necrotic  destruction,  so  that  thereby  a  means  is 
afforded  for  the  development  of  more  or  less  deep  and  extensive  ulcers. 
The  frequency  with  which  ulceration  of  the  larynx  takes  place  in  this 
manner,  and  how  often  it  is  due  to  other  causes,  can  at  present  not  be 
decided.  It  is  certain,  however,  that  diphtheric  and  pseudodiphtheric 
affections,  which  often  were  held  responsible  by  earlier  writers,  have 
gradually  become  less  frequently  a  cause  of  this   condition. 

Another  mode  of  origin  for  ulceration  of  the  larynx,  however, 
appears  quite  frequent.  The  condition  then  results  from  small,  at 
first  shallow,  fissures  and  erosions  upon  the  postero-internal  w^all  of  the 
larynx,  between  the  arytenoid  cartilages  and  the  points  of  attachment 
of  the  vocal  bands,  which  lesions,  obviously,  develop  as  a  consequence 
of  the  hyperemia  and  dryness  of  the  mucous  membrane  and  the  increased 


SYMPTOMS  AND  COMPLICATIONS.  241 

respiratory  activity  and  frequent  cough.^  When  such  small  fissures  and 
epithelial  excoriations  have  once  developed,  the  process,  owing;  to  the 
tendency  to  tissue-degeneration  at  the  heiglit  of  severe  attacks  of  typhoid 
fever,  readily  extends,  and  if  unfavorably  situated  and  accompanied 
by  other  complicating  conditions,  attains  a  considerable  de[)th. 

Both  the  ulcers  resulting  from  the  necrosis  of  follicles,  and  those  due 
to  fissures  and  erosions,  may  involve  and  penetrate  the  mucous  mem- 
brane to  a  varying  extent.  When  they  involve  its  entire  thickness, 
perichondritis  with  perichondritic  abscesses,  and  even  rather  extensive 
necrosis  of  cartilage,  with  correspondingly  severe,  dangerous,  and,  under 
the  most  favorable  circumstances,  protracted  sequels,  may  result. 

Whether  such  deep  ulcers  can,  by  reason  of  their  mode  of  origin,  be 
designated  decubital  in  the  strict  sense  (Dittrich) — as  has  been  done  by 
earlier  writers — does  not  appear  to  be  definitely  determined.  I  believe  that 
at  the  present  day  a  correct  conception  cannot  be  formed  of  the  mechanism 
by  which  such  ulceration  is  brought  about. 

The  seat  of  the  laryngeal  ulceration  is  constant,  almost  typical.  As 
has  been  mentioned,  it  is  most  frequently  situated  upon  the  posterior 
wall  of  the  larynx,  extending  at  times  to  the  contiguous  portions  of  the 
attachments  of  the  vocal  bands,  in  the  latter  situation,  it  is  true,  almost 
solely  in  the  form  of  slight  erosions.  With  this  seat  of  predilection  for 
the  ulceration  is  associated  the  fact  that  secondary  perichondritis  and 
necrosis  of  the  cartilage  involve  in  the  majority  of  cases  the  cricoid 
and  arytenoid  cartilages.  Typhoid  ulcers  appear  to  be  quite  rare  at 
other  situations  in  the  interior  of  the  larynx.  I  have  in  one  instance 
observed,  in  association  with  ulceration  upon  the  posterior  wall,  erosion 
of  the  left  ventricular  band. 

Ulceration  occurs  not  much  less  commonly  upon  the  epiglottis  than 
it  does  upon  the  posterior  wall,  but  in  general  it  is  there  much  less  deep 
and  less  extensive.  Under  such  circimistances  laryngoscopic  examina- 
tion often  discloses  numerous  small  shallow,  ragged,  ulcers  occupying 
the  margin  of  the  epiglottis.  I  have  frequently  observed  them  in  asso- 
ciation with  follicular  swelling  and  ulceration  in  the  throat,  especially 
with  the  peculiar  erosive  inflammation  of  the  soft  palate  and  the  tonsils 
previously  mentioned.  Quite  commonly  the  ulcers  extend  do^vn  to  the 
cartilage  and  cause  exfoliation  of  small  portions.  Only  exceptionally 
does  extensive  necrosis  of  the  epiglottis  take  place,  leaving  large  defects. 
Especially  severe  cases  of  this  kind  have  been  recorded  in  the  literature 
by  Moore,^  West,^  and  others.     I  have  personally  observed  at  autopsy 

*  See  also  Stork,  Klinikder  Krankheiten  des  Kehlkopfes,  Vienna,  1880,  pp.  259,  260.. 
2  Trans.  Path.  Soc,  1883,  vol.  xxxiii.,  p.  38.  ^  Ibid.,  p.  37. 

16 


242  TYPHOID  FEVER. 

in  one  instance  destruction  of  one-third  of  the  epiglottis  by  necrosis, 
and  in  another  instance  necrosis  of  more  than  half.  Nevertheless,  apart 
from  these  extensive  lesions,  affections  of  the  epiglottis  are  by  no  means 
so  dangerous  as  those  of  the  interior  of  the  larynx.  They  are  often  not 
even  noticed  by  the  stuporous  patient,  and  often  become  appreciable 
only  through  difficulty  in  swallowing.  Only  in  cases  in  which  the  con- 
stitutional condition  is  grave,  or  where  very  extensive  defects  exist  in 
the  epiglottis,  does  aspiration-pneumonia  develop. 

The  much  more  frequent  profound  disturbances  due  to  ulceration 
of  the  interior  of  the  larynx  are  of  varied  kind.  Before  the  ulcerative 
process  extends  deeply — more  frequently,  indeed,  if  this  is  the  case — 
edema  of  the  glottis  may  develop.  At  times  it  appears  quite  unex- 
pectedly, and  then  increases  with  such  rapidity  that  even  in  hospitals 
suffocation  has  occurred  before  tracheotomy  could  be  performed. 

A  further  serious  danger  resides  in  the  possible  development  of 
perichondritic  abscess  and  necrosis  of  cartilage.  The  cricoid  cartilage, 
■which  is  most  frequently  involved,  may  be  destroyed  throughout  almost 
its  entire  extent.  Next  to  it  in  frequency  the  arytenoid  cartilages  are 
involved,  and  are  frequently  bathed  in  pus  and  partially  or  wholly  exfo- 
liated. In  one  instance  I  observed  expectoration  of  an  entire  arytenoid 
cartilage ;  this  sometimes  occurs  also  in  cases  of  typhus  fever.  That 
such  perichondritic  processes  are  more  likely  than  simple  ulcers  to 
cause  marked  tumefaction  of  the  mucous  membrane  and  stenotic  edema 
of  the  larynx  is  obvious.  If,  however,  in  such  cases  the  impending 
danger  to  life  is  averted  by  tracheotomy,  the  patients  are  still  exposed 
to  the  most  serious  consequences  due  to  extensive  ulceration  and  corre- 
sponding loss  of  cartilage.  The  slightest  of  these  disturbances  consists 
in  the  necessity  of  wearing  a  cannula  for  a  considerable  length  of  time, 
and  the  persistence  for  a  further  period  of  a  certain  degree  of  hoarse- 
ness. When  severe  cicatricial  stenosis  of  the  larynx  develops,  some 
patients  must  continue  to  wear  a  cannula  permanently  ;  or  in  favorable 
cases  some  degree  of  improvement  may  be  secured  by  long  courses  of 
dilatation  with  bougies. 

Fortunately,  secondary  suppuration  and  gangrene  in  the  cellular 
tissues  of  the  neck  and  its  vicinity  are  rare  in  connection  with  suppu- 
rative perichondritis.  In  pne  instance  I  observed  purulent  posterior 
mediastinitis,  and  in  a  number  of  instances  burrowing  of  the  pus  into 
the  anterior  mediastinum.  Quite  exceptionally  (Wilke),  extensive 
cutaneous  emphysema,  involving  the  larger  portion  of  the  body,  has 
been  described  in  tlic  sequence  of  perforation  of  the  thyroid  cartilage. 
Whether  typhoid  perichondritis  may  develop  directly  and  independ- 


SYMPTOMS  AND  COMPLICATIONS.  243 

ently  without  antecedent  ulceration  of  the  mucous  membrane,  as  is 
believed  by  Dittrich  and  others,  is  as  yet  undemonstratcd.  But  with 
our  recent  knowledge  with  regard  to  typhoid  osteomyelitis  and  peri- 
ostitis, the  question  can  by  no  means  be  ignored.  I  have  personally 
encountered  a  case  in  which,  on  careful  laryngoscopic  examination,  the 
arytenoid  cartilages,  the  epiglottis,  and  the  entire  interior  of  the  larynx 
were  found  clear,  while  circumscribed  inflammation  of  the  thyroid  car- 
tilage, attended  from  the  outset  with  swellmg  of  the  anterior  portion  of 
the  neck,  developed.  There  resulted  suppuration,  burrowing  of  the 
pus  between  the  deep  muscles  of  the  neck,  and  exfoliation  of  a  portion 
of  cartilage  about  three-quarters  of  an  inch  in  diameter,  followed 
finally  by  uncomplicated  recovery  without  stenosis  or  impairment  of 
the  voice.  On  the  whole,  the  thyroid  cartilage  appears  to  be  by  far 
the  least  frequently  involved  of  all. 

The  literature  contains  a  large  number  of  isolated  cases  of  extensive 
typhoid  necrosis  of  the  larynx.  Extensive  necrosis  of  entire  cartilages  or 
of  individual  portions  of  cartilage  have  been  recoi'ded  by  Pachmayer/ 
DeBroeu,'^  Gilliard,^  Sekretan/  Dutheil,^  and  others.  A  collective  report  of 
the  cases  of  severe  typhoid  involvement  of  the  larynx  (200  cases),  together 
with  14  personal  cases,  has  been  made  by  Liiuing.''  He  found  affections  of 
the  larynx  in  almost  one-tenth  of  all  cases  of  typhoid  fever  that  came  to 
autopsy.  Half  of  these  consisted  in  simple  superficial  ulceration  ;  the  others 
in  more  profound  ulceration,  in  part  with  necrosis  of  cartilage.  The  state- 
ments of  various  writers  with  regard  to  the  frequency  of  laryngeal  ulcera- 
tion vary  quite  remarkably.  While  Murchison,  who  bases  his  opinion 
upon  the  observations  of  Jenner,  Trousseau,  Louis,  Bartlett,  Wilks,  and 
others,  as  well  as  his  own,  designates  it  as  an  "occasional,"  evidently  not 
frequent,  condition,  Hoffmann  observed  laryngeal  ulceration  at  Basle  in  28 
of  2,50  autopsies,  and  Griessinger  in  26  per  cent,  of  his  fatal  cases.  In 
Hamburg  we  observed  extensive  ulceration  of  the  larynx  in  37  of  349 
autopsies. 

With  regard  to  the  frequency  of  ulceration  of  the  larynx  in  accord- 
ance with  age  and  sex,  children  appear  to  be  rarely  attacked.  Men 
exhibit  ulceration  of  the  larynx  far  more  frequently  than  women.  Two- 
thirds  of  the  cases  under  my  observation  occurred  in  men.  In  this 
connection  antecedent  predisposing  influences  probably  play  an  impor- 
tant role,  especially  chronic  pharyngeal  and  laryngeal  catarrh,  such  as 
occurs  predominantly  in  men,  largely  as  a  result  of  smoking  and  of 
alcoholism. 

It  is  doubtful  whether  ulceration    of  the   larynx  occurs  with  especial 

^  Verhandl.  d.  Wiirzburger  med.  GeseUsch.,  1869. 

==  Presse  med.  Belff.,  1869,  No.  21.  s  Ibid.,  No.  20. 

*  Rev.  med.  de  la  Suisse  Rom.,  August,  1883.  ^  These,  Paris,  1869. 

^  ' '  Die  Larynx-  und  Tracheastenosen  im  Verlaufe  des  Abdominaltyphus  und  ihre 
Behandlung,"  Arch.  f.  klin.  Chir.,  1884,  Bd.  xxx. 


244  TYPHOID  FEVER. 

frequency  in  certain  countries  and  localities.  Quite  striking  differences  in 
frequency,  however,  may  be  observed  at  certain  times  and  durina:  certain 
epidemics.  This  is  true  of  typhoid  fever  as  well  as  of  the  laryngeal  ulcera- 
tion of  typhus  fever,  which  at  times  nuiy  be  a  very  cons]>icuous  feature  of 
the  epidemic  ;  for  instance,  during  the  last  eindemic  of  typhus  fever  at 
Berlin,  when  4  per  cent,  of  all  the  typhus  patients  under  my  observation 
presented  more  or  less  marked  involvement  of  the  larynx. 

The  time  of  onset  and  the  duration  of  laryngeal  ulceration  in  the 
course  of  typhoid  fever  ari'e  extremely  difficult  to  determine,  inasmuch 
as  the  milder  lesions,  as  well  as  those  that  subsequently  pursue  a 
severe  course,  are  likely  to  be  almost  free  from  symptoms  at  the  out- 
set. The  deeply  stuporous  patients  do  not  complain,  and  the  physician, 
under  such  conditions,  has  little  reason  and  opportunity  for  examination 
of  the  larynx.  It  may  be  said  in  general  that  ulceration  of  the  larynx 
occurs  chiefly  at  the  height  of  the  disease  and  in  the  latter  part  of  the 
febrile  stage,  principally  at  a  time  when  exfoliation  of  the  sloughs  and 
cicatrization  of  the  ulcers  in  the  intestme  are  taking  place.  In  isolated 
instances  I  have  observed,  both  by  laryngoscopic  examination  and  at 
autopsy,  ulceration  of  the  larynx  as  early  as  the  beginning  of  the  third 
week ;  m  one  instance,  even  at  the  beginning  of  the  second  week,  there 
was  a  deep  ulcer  upon  the  posterior  wall  of  the  larynx. 

When  the  affections  of  the  larynx  give  rise  to  symptoms,  these  will 
be  most  variable — local  pain,  difficulty  in  swallowing  associated,  with 
aspiration  of  food  into  the  air-passages,  irritative  cough  on  speaking  and 
on  deep  breathing,  hoarseness,  and  even  aphonia.  At  times  the  symp- 
toms of  acute  edema  of  the  glottis  may  set  in  quite  suddenly,  before 
there  is  any  reason  for  thinking  of  serious  disease  of  the  larynx. 
Every  t^^phoid  patient  with  laryngeal  symptoms  should  therefore  be 
subjected  to  special  observation.  This  applies  particularly  to  the 
throat  and  larynx  in  severe  cases  where  the  patients  are  stuporous. 
With  every  increase  in  respiratory  frequency,  with  the  development  of 
dyspnea  and  cyanosis,  involvement  of  the  larj'nx  should,  among  other 
things,  always  be  thought  of  as  a  cause.  More  than  one  unfortunate 
case  is  known  in  which  superficial  observers  attributed  such  symptoms 
to  bronchitis,  lobular  pneumonia,  or  to  the  existing  infiltration  of 
the  lungs  alone,  and  in  which  the  autopsy  showed  that  death  was  due 
to  edema  of  the  glottis,  for  which  tracheotomy  should  have  been  per- 
formed promptly.  In  contrast  with  the  profound  conditions  just  referred 
to,  it  is  comforting  to  know  that  in  the  large  majority  of  cases  ulcera- 
tion of  the  larynx  remains  superficial,  extends  but  little,  and  heals 
without  sequels.  The  laryngeal  affection  should  not  therefore  be 
considered  as  of  too  grave  prognostic  significance. 


SYMPTOMS  AND  COMPLICATIONS.  245 

Following  the  suggestion  of  liokitansky,  some  writers,  especially 
the  French,  have  applied  the  designation  "  laryngotyphoid "  to  those 
cases  in  which  extensive  laryngeal  symptoms  appear  quite  early.  '  I 
considered  this  designation  arbitrary  and  scarcely  justified.  Some 
remarks  upon  paralysis  of  the  vocal  cords  will  be  made  in  the 
succeeding  chapter. 

Trachea  and  I/arge  Bronchi. — In  these  parts  also  dry  catarrh 
or  catarrh  attended  with  but  scanty  secretion  plays  a  certain  role.  At 
autopsy  tracheitis  and  bronchitis  are  among  the  conditions  most  con- 
stantly found  (see  Anatomy).  These  conditions  are  manifested  clini- 
cally by  dry  cough,  tenderness,  and  a  sense  of  soreness  behind  the 
sternum,  and  these  symptoms  are  more  frequently  complained  of  since 
the  tracheitis  is  likely  to  appear  at  the  end  of  the  first  and  the  begin- 
ning of  the  second  week ;  therefore,  at  a  time  when  intelligence  is  still 
preserved.  On  auscultation,  coarse,  dry  rales,  sonorous  and  sibilant, 
can  be  heard.  The  superficial  erosions  of  the  mucous  membrane  that 
are  encountered  on  post-mortem  examination  give  rise  to  no  special 
clinical  symptoms. 

Diphtheric  affections  of  the  trachea  and  the  large  bronchi  are  still 
more  rare  than  those  of  the  nasopharynx  and  larynx.  Griessinger 
refers  to  pseudomembranous  affections  of  the  larynx  and  the  trachea 
in  cases  of  malignant  course,  but  I  have  never  observed  such  condi- 
tions. Eisenlohr '  has  described  a  form  of  fibrinous  bronchitis  devel- 
oping as  early  as  the  end  of  the  second  week,  which  extends  into  the 
smallest  bronchi  and  heals  without  complication.  A  fatal  case  of  this 
character  is  mentioned  by  Brault.^ 

Involvement  of  the  bronchial  glands  is  often  observed  at 
post-mortem  examination,  and  is  well  known.  It  is  doubtless  analo- 
gous to  that  of  the  mesenteric  glands,  and  is  probably  specific,  due  to 
the  bacillus  of  Eberth.  In  the  cadaver  recent  medullary  swelling  of 
the  glands  is  quite  generally  found,  at  times  of  such  considerable  extent 
that  the  possibility  of  compression  of  the  trachea  or  of  the  large  bronchi 
in  consequence  can  readily  be  conceived.  In  some  instances  in  severe 
cases  of  typhoid  fever  I  have,  in  fact,  observed  remarkably  enfeebled, 
soft  breathing  upon  one  side,  when  no  adequate  explanation  could  be 
based  upon  disease  of  the  lungs  or  the  pleura,  and  which  persisted  so 
long  that  neither  occlusion  by-  mucus  nor  other  transitory  influences 
could  be  considered  the  cause  of  the  condition.  The  respiratoiy  murmur 
became  normal  again  with  subsidence  of  the  fever.  I  have  lost  no  case 
of  this  kind,  and  therefore  do  not  venture  to  consider  the  condition  as 

1  Berli7i.  Jdin.  Woch.,  1876,  No.  31.  2  Progres  med.,  1881,  No.  19. 


246  TYPHOID  FEVER. 

with  certainty  one  of  bronchial  stenosis  dnc  to  glandular  enlargement. 
In  a  fatal  case  of  empyema  I  "was  able  to  demonstrate  purulent-putrid 
disintegration  of  a  mass  of  bronchial  lymphatic  glands  as  the  point  of 
origin  of  the  complication. 

The  catarrh  of  the  medium-si^ed  and  smallest  ramifi- 
cations of  the  bronchial  tubes  is  a  direct  continuation  of  the 
catarrhal  conditions  present  in  the  larger  air-passages.  By  reason  of 
the  constiincy  of  its  occurrence,  the  peculiarity  of  its  symptoms  and  its 
rourse,  I  believe  that  it  can  be  definitely  looked  upon  as  a  specific  typhoid 
symptom,  and  may  be  attributed  directly  to  the  action  of  toxins  or  of 
the  bacilli.  Although  Murchison  and  subsequent  writers  do  not  attach 
to  it  this  significance,  and  although  the  former  even  believes  that  he 
observed  bronchitis  far  more  frequently  m  cases  of  typhus  than  in  those 
of  typhoid  fever,  this  position  is  not  wholly  in  accordance  with  the 
facts.  The  bronchitis  attending  typhus  fever  pursues  its  course  with 
much  more  pronounced  symptoms,  particularly  more  marked  cough  and 
more  abundant  secretion ;  while  in  cases  of  typhoid  fever,  by  reason  of 
the  slight  degree  of  swelling  and  sponginess  of  the  mucous  membrane  and 
the  small  anioimt  of  secretion,  cough  is  less  frequent  and  less  severe,  and 
expectoration  is  almost  always  wanting.  If,  however,  the  patients  are 
examined  carefully  at  the  height  of  the  febrile  stage,  physical  signs  of 
bronchitis  and  bronchiolitis — at  times,  it  is  true,  but  slight — will  always 
be  demonstrable  in  some  degree.  As  early  as  the  end  of  the  first  or 
the  beginning  of  the  second  week,  and  from  this  time  on  throughout  the 
entire  febrile  period,  roughened,  frequently  enfeebled,  vesicular  inspira- 
tion is  audible,  at  times  with  prolongation  of  expiration,  and  sometimes 
with  an  abmidance,  and  at  other  times  with  a  scarcity,  of  dry  rales  of 
sonorous  and  sibilant  quality. 

The  seat  of  such  catarrhal  conditions  is  especially  in  the  lower  lobes. 
Not  rarely,  and  especially  in  severe  cases,  they  extend  throughout  the 
entire  lung.  In  those  situations  in  which  extensive  bronchiolitis  is 
present,  marginal  emphysema  may  develop.  Rarely,  the  anterior  and 
upper  portions  of  the  lungs  are  involved  first  and  most  markedly. 
Such  cases  should  be  viewed  with  suspicion,  and  be  investigated  for 
complications  with  especial  care. 

It  has  been  stated  that  by  no  means  all  cases  of  bronchitis  are 
attended  with  cough,  and  that  when  patients  do  exhibit  a  short,  dry 
cough  there  may  be  only  a  scanty,  vitreous,  viscid  expectoration,  if  any. 
More  violent  and  more  frequent  cough,  or  abundant  mucopurulent 
expectoration,  demands  careful  investigation  for  the  presence  of  other 
alterations. 


SYMPTOMS  AND  COMPLICATIONS.  247 

In  general  the  catarrhal  manifestations  arc  of  c(jnsiderable  signifi- 
cance both  from  a  diagnostic  and  from  a  j)rognostic  standpoint.  In 
diagnosis  the  detection  of  diffuse  bronchitis  is  especially  of  significance 
because  other  infections  that  may  readily  be  confounded  with  typhoid 
fever,  as,  especially,  febrile  protracted  intestinal  catarrh,  are  unattended 
with  it.  On  the  other  hand,  it  is  noteworthy  in  the  diagnosis  of  typhoid 
fever,  and  under  some  conditions  decisive,  when  apparent  intestinal 
catarrh,  even  of  slight  intensity,  is  from  the  outset  associated  with 
extensive  bronchitis.  It  is  to  be  noted  that  the  degree  and  the  extent 
of  the  bronchitis  in  cases  of  typhoid  fever  need  by  no  means  correspond 
with  the  severity  of  the  case  in  general.  There  are  mild  cases  with 
markedly  predominant  bronchitis.  The  reverse,  it  is  true,  is  less 
common.  From  a  prognostic  point  of  view  it  is  also  noteworthy  that 
after  intense  catarrhal  conditions  of  early  onset,  severe  involvement  of 
the  lung  immediately  adjacent  is  likely  subsequently  to  occur. 

In  addition  to  simple  typhoid  bronchitis,  the  rare  occurrence  of  putrid 
bronchial  disorders  is  worthy  of  note.  I  have  repeatedly  observed 
them,  and  have  noted  their  disappearance  without  traces  at  the  termina- 
tion of  the  attack  of  typhoid  fever.  In  isolated  cases,  on  the  other 
hand,  they  probably  give  rise  to  small  bronchiectases  or  circmnscribed 
destruction  of  pulmonary  tissue,  occasionally  with  consecutive  putrid 
pleural  exudates.  The  atelectasis  and  the  lobular  pneumonia  that  are  so 
frequent  in  the  course  of  typhoid  fever  are  intimately  related  to  the 
bronchitis,  particularly  to  the  capillary  variety.  Clmically  these  con- 
ditions are  often  recognizable  with  difficulty  if  at  all,  and  this  is 
especially  true  of  atelectasis. 

Bronchopneumonia,  which  occasionally  manifests  itself  by 
increase  in  the  fever,  change  in  the  character  of  the  expectoration,  and 
occasionally  also  by  distinctive  auscultatory  signs,  has  been  little  investi- 
gated from  the  etiologic  point  of  view.  In  the  majority  of  cases  this 
condition  is  doubtless  to  be  included  among  the  true  complications.  In 
the  small  number  of  cases  thus  far  investigated,  principally  the  pyogenic 
bacteria,  streptococci,  and  staphylococci  have  been  found.  Without 
doubt,  bronchopneumonia  may  also  be  of  specific  typhoid  character,  as 
is  shown  by  the  investigations  of  Polynere,^  rinkler,^  and  others,  who 
were  able  to  demonstrate  the  bacillus  of  Eberth  as  the  excitmg  cause  of 
the  inflaromation.  The  extremely  grave  cases  of  acute  edema  of  the 
lungs,  which  are  fortunately  rare,  are  also  dependent  upon  extensive 

1  These,  Paris,  1889,  cited  by  Finkler. 

^  Die  acuten  Lungenentzundungen^  Wiesbaden,  1889. 


248  TYPHOID  FEVER. 

bronc'liopncumouia  aud  cardiac  weakness  with  acute  onset,  or  with 
acute  intensification. 

Bront'hopneuiiioiiia  likewise  constitutes  the  usual  basis  for  the 
hypostatic  congestion  of  the  lower  lobes  of  the  lungs  that  occurs 
so  frequently  in  the  latter  part  of  the  febrile  stage ;  its  development  is 
also  favored,  however,  by  the  weixkness  of  the  heart  and  the  influence 
of  the  posture  of  the  body  upon  the  distribution  of  the  blood.  From 
all  that  has  been  said,  it  will  appear  that  hypostatic  congestion  occurs 
only  in  debilitated  mdividuals  ^\•itll  severe  attacks,  and  it  therefore 
forms  an  importiuit  link  in  the  chain  of  imfavorable  occurrences  in  the 
course  of  typhoid  fever.  In  patients  presenting  especially  severe  infec- 
tion and  already  much  reduced,  the  hypostasis  develops  as  early  as  the 
first  half  of  the  febrile  stage  or  at  its  height,  and  it  is  then  of  especially 
mifavorable  omen.  It  is  more  common,  it  is  true,  particularly  in  cases 
of  protracted  course,  toward  the  end  of  the  febrile  period,  or  even  at  the 
beginning  of  convalescence.  I  have  occasionally  obsei'ved  it  also  during 
relapses  with  prolonged  course  following  an  antecedent  severe  attack. 
In  the  absence  of  systematic  careful  examination  of  the  patient,  for 
which  there  is  often  no  special  indication,  this  hypostasis  may  be  readily 
overlooked,  as  in  itself  it  gives  rise  neither  to  elevation  of  temperature, 
pain  on  breathing,  nor  to  increased  cough,  and  by  no  means  always  to 
changes  in  the  frequency  and  the  character  of  the  respirations.  On  the 
other  hand,  physical  examination  will  at  once  yield  the  desired  infor- 
mation. There  will  be  found  slightly  tympanitic  or  even  markedly 
impaired  resonance,  posteriorly  and  mferiorly,  at  first  often  confined  to 
one  side,  though  subsequently  usually  marked  upon  both  sides.  The 
vocal  fremitus  is  generally  moderately  mcreased  if  the  patient  can  be 
induced  to  submit  to  investigation  of  this  phenomenon,  but  not  rarely 
it  is  enfeebled  and  even  absent  when  the  bronchi  are  filled  with  secre- 
tion. The  respiratory  murmur  is  accordingly  indistinct,  soft,  no  longer 
vesicular,  and  expiration  is  prolonged,  with  a  bronchial  character.  If 
the  congestion  progresses  further,  the  respiratory^  murmur  becomes 
markedly  bronchial  and  the  rales  amphoric.  Not  rarely  inspiration  is 
completely  obscured  by  crepitant  or  subcrepitant  rales. 

With  improvement  in  the  remaining  symptoms  of  the  disease  such 
consolidation  usually  undergoes  resolution,  as  a  result  of  appropriate 
treatment  or  without  special  intervention,  and  is  usually  followed  by  no 
sequels.  In  some  cases,  with  continued  progress  of  the  disease  the 
symptoms  of  consolidation  may  increase  and  extend.  Considerable 
elevation  of  temperature  may  occur  associated  with  repeated  chilliness 
or  even  a  marked  chill.     Under  such    circumstances    a    condition  of 


SYMPTOMS  AND  COMPLICATIONS.  249 

hypostatic  pneumonia  may  appropriately  be  spoken  of".  This  Ls 
undoubtedly  dependent  upon  the  secondary  invasion  of  exciting  agents 
of  inflammation,  principally  through  the  inspired  air ;  less  commonly 
through  the  circulation.  Whether  the  typhoid-bacillus  i)lays  an  etiologic 
rdle  in  these  complications,  and  if  so  with  what  frequency,  is  as  yet 
unknown. 

Hypostatic  pneumonia  is  one  of  the  most  dangerous  complications 
of  typhoid  fever.  Death  occurs  in  the  majority  of  cases.  Should 
recovery  ensue,  slow  disappearance  of  the  physical  signs ;  with  a  pro- 
tracted course  for  the  entire  process,  is  the  rule.  Local  complications — 
abscess  of  the  lung,  gangrene,  and  pleurisy  with  effusion — appear  to  me 
to  be  less  common  after  hypostatic  pneumonia  than  after  other  inflam- 
matory processes  in  the  lungs. 

Of  1830  cases  of  typhoid  fever  of  which  I  have  notes,  signs  of  consoli- 
dation or  inflammatory  congestion  of  the  lower  lobes  were  present  in  121. 
In  the  overwhelming  majority  of  cases  the  onset  of  the  condition  occurred  in 
the  second  and  the  third  week,  most  frequently  between  the  end  of  the 
second  and  the  middle  of  the  third  week  ;  and  of  the  patients  in  question,  65 
died.  The  ohservations  of  Liebermeister  difier  but  little  from  my  own. 
He  found  among  1420  cases,  100  of  hypostatic  congestion,  with  50  deaths. 
It  is  noteworthy  that  congestion  and  hypostatic  pneumonia  are  far  less 
common  in  children  than  in  adults.  This  is  no  doubt  partly  due  to  the 
shorter  duration  and  the  generally  slighter  intensity  of  the  attack  of  typhoid 
fever  in  children,  but  especially  to  the  fact  that  the  determining  cause  in 
adults,  namely,  the  weakness  of  the  heart,  is  much  less  commonly  efiective 
in  children.  Especially  convincing  in  this  connection  also  is  the  fact  that 
lobar  pneumonia,  the  onset  of  which  is  due  less  to  the  cardiac  weakness 
than  to  the  infection  itself,  is  in  my  experience  no  less  common  in  children 
than  in  adults. 

I/Obar  pneumonia  is  less  frequent  in  the  course  of  typhoid  fever 
than  hypostatic  congestion  or  consolidation.  Among  the  different 
varieties  true  croupous  pneumonia  plays  the  principal  role,  and  is  one 
of  the  more  important  actual  complications  of  the  disease.  It  is  almost 
exclusively  dependent  upon  the  Frankel-Weichselbaum  diplococcus ; 
with  extreme  rarity  upon  the  bacdlus  of  Friedlander.  It  occurs,  as  a 
rule,  at  the  height  or  toward  the  end  of  the  febrde  period.  It  occurs 
very  rarely,  according  to  my  experience,  during  convalescence  or  in  the 
course  of  relapses  of  considerable  duration. 

Although  the  onset  and  the  course  of  genuine  fibrinous  pneumonia 
are  usually  most  characteristic,  the  symptoms  when  it  occurs  as  a  com- 
plication of  typhoid  fever  are  exceedingly  inconstant.  Even  the  manner 
in  which  it  manifests  itself  is  extremely  variable.  Generally  it  sets  in 
with  a  single  or  repeated  chilliness,  or  a  true  chill,  although  these  s^^np- 
toms   may  be  wholly  wanting.     The  absence   of  chilly   symptoms   is 


250  TYPHOID  FEVER. 

observed  especially  in  previously  debilitatotl  or  in  elderly  persons,  or 
when  the  pneumonia  develops  at  a  late  sta^e  in  severe  protracted  cases. 
Under  such  circumstances  even  noteworthy  elevation  or  characteristic 
com'se  of  the  tempemture  may  be  wanting. 

As  a  rule,  the  onset  of  the  pneumonia  is  attended  with  rapid  rise  in  the 
body-temperatm-e,  Avhich  may  then  continue  for  da>s  at  an  abnormally 
higli  level,  in  the  form  of  a  remittent  continued  fever.  When  the 
pneumonia  develops  during  the  last  portion  of  the  febrile  period  and  the 
resolution  coincides  with  the  termination  of  this  period,  there  may 
occasionally  be  a  definite  critical  decline  in  temperature.  If,  on  the 
other  hand,  the  pneumonia  undergoes  resolution  in  the  course  of  the 
fastigium,  the  critical  decline  is  wanting,  as  a  rule,  and  defervescence 
by  lysis  takes  its  place. 

All  cases  of  pneumonia,  even  those  that  do  not  give  rise  to  marked 
elevation  of  temperature,  are  attended  with  considerable  increase  in 
pulse-frequency ;  and  in  debilitated  persons  are  generally  associated 
with  reduction  in  size  and  considerable  lowering  of  tension  of  the  pulse. 
A  corresponding  increase  in  frequency  of  respiration  and  in  cyanosis 
are  naturally  quite  common.  There  is  therefore  all  the  more  reason  to 
look  for  these  symptoms  in  cases  of  suspected  pneumonia  during  typhoid 
fever,  because  under  these  circumstances  subjective  complaint,  particu- 
larly of  pain  in  the  side,  as  well  as  of  cough  and  expectoration,  is  often 
wanting.  The  absence  of  pain  and  the  slight  character  of  the.  cough 
are  probably  dependent  upon  the  lessened  irritability  of  the  patient, 
associated  with  the  obscuration  of  consciousness ;  and  the  absence  of 
expectoration  upon  the  fact  that  the  patient  expels  the  sputum  imper- 
fectly and  swalloAvs  it  again,  in  part  possibly  also  upon  its  secretion  in 
relatively  small  amount.  When  the  patient  ejects  the  sputum,  it  may 
be  characteristically  viscid,  rusty,  or  even  more  hemorrhagic.  I  have 
an  impression  that  the  last  mentioned  peculiarity  is  more  frequent  in 
cases  of  pneumonia  complicating  typhoid  fever  than  in  those  of  genuine 
pneumonia. 

With  regard  to  its  seat  and  the  physical  signs,  fibrinous  pneumonia 
attending  typhoid  fever  differs  little  from  that  arising  independently. 
As  to  the  course,  the  height  of  the  infiltration  appears  to  me  to  be  at 
times  reached  more  slowly,  and  resolution  also  is  not  rarely  completed 
more  slowly  than  in  the  independent  form.  A  considerable  number  of 
cases  do  not  advance  beyond  the  symptoms  of  congestion.  That  they, 
nevertheless,  are  cases  of  fibrinous  pneumonia,  I  have  repeatedly  been 
able  to  establish  both  by  puncture  of  the  lung  during  life  and  by  the 
demonstration  of  the  characteristic  encapsulated  cocci  in  the  sputum. 


SYMPTOMS  AND   COMPLICATIONS.  251 

Fibrinous  pneumonia  is  not  one  of  the  more  common  complications  in 
the  course  of  typhoid  fever.  Its  occurrence,  however,  doubtless  exhibits 
great  variations  in  accordance  with  the  season  of  the  year,  the  locality,  and 
the  character  of  the  epidemic.  I  am  personally  not  in  possession  of  large 
statistics,  and  would  draw  conclusions  with  care  from  those  of  other  writers, 
as  a  large  proportion  of  the  cases  hitherto  reported  have  not  been  studied 
with  sufficient  care  from  the  bacteriologic  standpoint,  and  the  results  of 
study  of  the  remainder  are  unreliable.  Even  the  older  anatomic  statements 
are  to  be  accepted  with  reservation,  as  in  cases  of  typhoid  fever,  in  con- 
sequence of  certain  histologic  conditions,  the  pneumonia  dependent  upon 
encapsulated  cocci  may,  upon  section,  exhibit  an  unusual  color  and  a  smooth 
or  slightly  granular  surface. 

Age  and  sex  exert  no  influence  upon  complication  with  croupous 
pneumonia,  which  occurs,  as  has  been  indicated,  with  scarcely  less  fre- 
quency in  children  than  in  adults. 

The  role  played  by  the  diplobacillus  of  Friedlander,  as  compared  to  the 
Frankel-Weichselbaum  coccus,  in  the  development  of  pneumonia  in  the 
course  of  typhoid  fever,  is  obscure.  In  those  cases  in  which  examination  has 
been  made  as  to  this  point,  the  diplococcus  especially  has  been  found,  and 
only  in  rare  instances  the  bacillus  of  Friedlander,  which  I  have  personally 
been  able  to  demonstrate  in  only  1  case. 

Other  Varieties  of  I/obar  Pneumonia. — In  addition  to  hypo- 
static and  true  fibrinous  pneumonia,  other  varieties  of  lobar  pneumonia 
certainly  occur.  They  have,  as  yet,  not  been  thoroughly  investigated, 
and  a  portion  of  that  which  is  said  to  have  been  surely  demonstrated 
needs  still  further  mvestigation.  This  is  true,  above  all,  of  the  cases 
of  lobar  pneumonia  attributable  to  typhoid-bacilli  (Bruneau,^  Chante- 
messe,^  Polyn^re,^  Finkler  *).  Thus,  Polynere  found,  in  addition  to  the 
lobular  pneumonia  already  mentioned,  extensive  consolidation  due  to  the 
bacillus  of  Eberth.  Early  occurrence,  rapid  development,  and  tardy 
subsidence  of  the  infiltration  are  considered  as  characteristic  clinically 
of  this  form  of  the  disease.  Recently,  even  the  bacteriologic  diagnosis 
of  the  specific  typhoid  affections  of  the  lungs  and  the  pleura  has  been 
rendered  additionally  difficult  by  the  fact  that  the  Bacterium  coli,  which 
in  some  respects  closely  resembles  the  bacillus  of  Eberth,  has  under 
such  conditions  been  repeatedly  found  as  the  exciting  agent  of  the 
inflammatory  process. 

It  is  also  objected  by  opponents  of  the  view  that  specific  t^^phoid 
affections  of  the  lungs  occur,  that  in  the  cases  where  pure  cultures  of  the 
typhoid-bacilli  have  been  found,  the  cultures  were  made  so  late  that  the 
primary  invader  had  died  out  (see  section  on  Pathology). 

The  conditions  are  not  much  clearer  with  regard  to  the  lobar  pneu- 

^  "De  la  nature  des  complic.  broncho-pleuro-pulmonaires  de  la  fievre  typhoide, ' '' 
These,  Paris,  1893.  ^  Loc.  cit.  ^  Loc.  cit.  *  Loc.  cit. 


252  TYPHOID  FEVER. 

inouia  due  to  streptococci  or  staphylococci  than  with  regard  to  that  due 
to  typhoid-bacilli.  Undoubtedly  these  micro-organisms  play  an  impor- 
tant role  in  the  mixed  infections  that  frequently  are  associated  with 
the  development  of"  pneumonia  in  the  course  of  typhoid  fever.  They 
have  been  observal  both  in  association  with  pneumococci  and  with  the 
bacillus  of  Eberth  (Karlinsky  ^).  Streptococci  appear  to  be  the  sole  or 
tlie  ])rincipal  cause  of  })neumonia  more  frequently  than  sta})hyl()cocci. 
Thev  sive  rise  to  both  lobular  and  lobar  inflanmiation,-  the  latter 
obviously  the  result  of  the  confluence  of  multiple  contiguous  lobular 
foci.  Probably  they  are  also  the  principal  micro-organisms  causing 
the  secondary  inflammator}'  changes  attending  simple  hypostatic  con- 
gestion. 

Streptococci  and  staphylococci  certainly  play  a  role  also  in  the 
development  of  the  so-called  aspiration-pneumonia  of  typhoid  fever. 
I  have  reason  to  believe  that  the  former  are  especially  responsible  for 
the  severe  pneumonia  following  typhoid  ulceration  of  the  larj'nx  and 
perichondritis  of  the  larynx.  Apart  from  all  these,  the  streptococcic 
pneumonia  of  typhoid  fever  is  doubtless  to  be  most  frequently  considered 
as  one  of  the  manifestations  of  general  secondary  septic  infection. 
Under  such  circumstances  other  lesions  due  to  this  organism  can  be 
found  in  the  body  after  death,  and  often  even  during  life.  Only  recently 
we  were  able  to  demonstrate  in  a  man  twenty-five  years  old  embolic 
abscesses  of  the  kidneys,  associated  with  bilateral  pure  streptococcic 
pneumonia  in  addition  to  pleuritic  effusion.^ 

Just  as  septic  processes  generally  appear  at  a  late  stage  in  the 
course  of  the  disease,  owing  to  their  mode  of  development,  so  also  the 
pneumonia  dependent  upon  streptococci  and  other  pyogenic  organisms 
occurs  late.  It  is  almost  exclusively  the  late  febrile  period  or  that  of 
convalescence  in  which  it  occurs.  Its  source  under  these  conditions  is 
often  a  bed-sore,  or  phlegmonous  inflammation  of  the  skin  and  the 
subcutaneous  connective  tissue,  or  it  may,  of  course,  follow  still  other 
purulent  processes,  as,  for  instance,  phlebitis  and  circumscribed  peri- 
tonitis. 

Clinically,  streptococcic  and  staphylococcic  pneumonia,  apart  from 
microscopic  and  bacteriologic  examination,  can  be  differentiated  from 
the  other  varieties  only  with  very  great  difficulty.  Recently,  numerous 
attempts  have  been  made,  with  the  aid  of  the  exploratory  needle,  to  obtam 

1  Fortschr.  d.  Med.,  1889,  Bd.  viii. 

*  See  also  the  communications  of  Neumann,   Berlin,  klhi.  Work.,   1886,  No.  6; 
Finkler,   Verhandl.  d.  Cong.f.  inn.  Med.,  1888  and  1889  ;  and  Karlinsky,  loc.  cit. 
'  See  Koch,  Inaug.  Diss.,  Leipsic,  1897. 


SYMPTOMS  AND  COMPLICATIONS.  253 

material  from  the  lung  during  life  for  examination.  I  have  personally- 
availed  myself  of  this  method  repeatedly  without  injury  to  the  patient, 
but  would  advise  great  caution  in  its  application. 

It  should  be  emphasized  as  of  importance  from  the  clinical,  and 
especially  from  the  diagnostic,  point  of  view,  that  pneumonia  may  occur 
even  at  an  early  period  in  the  course  of  typhoid  fever,  at  times  so  early 
that  it  may  at  first  be  considered  as  an  independent  condition.  Thus, 
pneumonic  infiltrations  have  frequently  been  observed  in  the  first  week 
of  typhoid  fever,  even  in  the  first  days,  before  any  of  the  characteristic 
features  of  typhoid  have  been  manifested.  At  times  they  set  in  with 
one  or  more  chills  or  repeated  chilliness.  Unilateral  or  bilateral  con- 
solidation then  rapidly  follows ;  in  my  experience,  often  more  rapidly 
than  in  the  case  of  uncomplicated  frank  pneumonia.  Not  rarely,  under 
such  circumstances,  there  is  no  expectoration  whatever,  or  the  sputum 
is  but  scanty  and  is  not  characteristic,  containing  no  blood,  encapsulated 
cocci,  or  fibrinous  coagula ;  in  other  cases  the  sputum  is  blood-tinged  or 
actually  prune-juice-like  in  character.  Certain  of  the  subjective  mani- 
festations also  are  more  inconstant  than  in  cases  of  genuine  pneu- 
monia. Nevertheless,  headache  of  unusual  severity  and  more  or  less 
marked  stupor  are  soon  noticed,  and  at  the  same  time  or  a  few  days 
later  the  enlargement  of  the  spleen  appears.  If  suspicion  now  arises 
that  the  condition  may  not  be  one  of  ordinary  fibrinous  pneumonia, 
— at  this  time  influenza-pneumonia  is  frequently  thought  of, — the  situa- 
tion soon  becomes  clear,  especially  if  at  the  proper  time,  after  the 
disease  is  of  from  seven  to  nine  days'  duration,  critical  defervescence, 
or,  in  fact,  any  remission  in  the  symptoms  does  not  take  place,  but  the 
pneumonia  instead  remains  stationary,  and  a  continuance  or  an  increase 
in  the  enlargement  of  the  spleen,  roseolse,  meteorism, '  pea-soup-like 
stools,  and  bronchitis  in  the  previously  uninvolved  portions  of  the  lungs 
make  their  appearance.  Such  cases,  in  analogy  with  those  of  nephro- 
typhoid  previously  mentioned,  have  been  designated  pneumotyphoid. 
Rokitansky  ^  and  Griessinger,^  subsequently  Gerhardt  ^  and  Rindfleisch,* 
have  directed  attention  to  eases  pursuing  this  peculiar  course. 

Strictly  speaking,  the  designation  pneumotyphoid  should  be  employed 
only  when  the  bacillus  of  Eberth  has  been  demonstrated  as  the  sole, 
or  at  least  as  the  principal,  cause.  As  a  matter  of  fact,  such  cases 
possibly  occur  (Lupine  ^  and  others.     See  section  on  Pathology,  p.  116). 

1  Loc.  cit.  2  Loc.  cit. 

'  Thiiringisches  Correspondenzbl.,  1875,  No.  11,  and  Handb.  d.  Kinderhdlk.,  1874, 
Bd.  ii.,  S.  388.  *  Garpagni,  Inaug.  Diss.,  Wurzburg,  1875. 

^  Eev.  demed.,  1878,  and  Nouv.  diet,  demed.,  Jaccoud,  1880,  t.  xxviii. 


254  TYPHOID  FEVER.' 

As  yet,  however,  not  much  is  known  concerning  them.  Further  bac- 
teriologic  investigation  will  be  required  before  it  is  definitely  decided 
whether  such  cases  occur,  and  if  they  do,  with  what  frequency.  If  it 
be  sht)wn  that  pneumonia  may  be  caused  by  the  typhoid-bacilli  alone, 
it  will  then  be  necessary  to  determine  whether  there  is  any  support  for 
the  theory,  previously  mentioned,  that  a  direct  mvasion  of  the  typlioid 
virus  through  the  air-passages  may  occur,  or  to  what  degree  the  pneu- 
monia is  to  be  considered  as  due  to  an  unusually  early  and  rare  primary 
localization  t)f  the  contagium  which  has  gained  entrance  into  the  body 
through  the  customary  portals.  Between  such  cases  and  those  in  which 
the  pneumonic  consolidation  occurs  at  a  later  period  are  those  in  which, 
after  an  attack  of  ambulatoiy  typhoid  fever,  a  recrudescence  or  a  relapse 
sets  in  with  specific  pneumonic  infiltration. 

We  shall  in  the  future  probably  have  to  differentiate  from  pneumo- 
typhoid  in  the  true  etiologic  sense  those  cases  in  which  other  micro- 
organisms— pueumococci,  streptococci,  and  staphylococci — likewise  give 
rise  to  pneumonic  infiltration  in  the  mitial  stage  of  typhoid  fever.  Such 
conditions  represent  true  complications  during  a  period  m  which  com- 
plications rarely  occur,  and  in  these  cases  the  clinical  picture  of  typhoid 
fever  may  be  strangely  altered  and  at  times  even  wholly  obscured.  I 
have  personally  observed  cases  in  which  pneumonia  due  to  pueumo- 
cocci developed  during  the  first  week  of  an  attack  of  typhoid  fever, 
W'hile  roseola?  and  splenic  enlargement  appeared  only  subsequently,  and 
then  helped  to  clear  up  the  situation. 

Interesting  clinical  evidence  in  regard  to  these  atypical  forms  of  pneumo- 
typhoid  has  been  furnished  by  E.  Wagner/  but  neither  he  nor  his  prede- 
cessors were  able,  on  account  of  the  state  of  knowledge  at  the  time,  to  make 
an  etiologic  difTerentiation  of  their  cases.  To  be  sharply  discriminated  from 
the  cases  thus  far  mentioned — and  this  has  not  always  been  done,  even  until 
within  a  recent  period — are  those  forms  of  genuine  pneumonia  which,  in 
consequence  of  the  malignity,  in  the  symptomatic  sense,  of  their  typhoid-like 
course,  have  been  designated  pneumotyphoid,  or,  at  times,  typhoid  pneu- 
monia. The  condition  present  is  undoubtedly  one  of  inflammation  of  the 
lungs,  which  pursues  a  particularly  unfavorable  course,  in  consequence  of 
individual  circumstances,  or  because  it  constitutes  one  of  the  manifestations 
of  one  of  the  other  severe  infectious  disorders,  among  which  septicemia,  par- 
ticularly the  cryptogenetic  variety,  is  to  be  mentioned  above  all.  In  addi- 
tion to  septic  pneumonia,  the  mixed  infections  of  tuberculosis  with  the  pyogenic 
agents  that  have  been  repeatedly  mentioned  have  been  considered  as  pneu- 
motyphoid or  typhoid-pneumonia.^ 

Abscess  of  the  lung"  is  considered  an  exceedingly  rare  complica- 
tion of  typhoid  fever.     Abscesses  are  probably  encoimtered  most  fre- 

1  Deutsch.  Arch.  f.  klin.  Med..,  Bd.  xxxv.  and  xlii. 
■■'  See  the  statistics  of  E.  Wagner. 


SYMPTOMS  AND  COMPLICATIONS.  255 

quently  as  metastatic  phenomena  associated  witli  complicating  general 
pyemia ;  they  also  exceptionally  occur  as  sequels  of  hjbar,  fibrinous 
pneumonia.  Two  cases  of  the  latter  variety  have  come  under  my  per- 
sonal observation.  As  they  occur,  like  the  primary  disease,  especially 
in  the  later  stages  of  typhoid  fever,  they  give  rise  under  the  most  favor- 
able conditions  to  considerable  retardation  of  convalescence,  if  they  do 
not  act  as  the  cause  for  a  fatal  termination  of  the  disease.  Without 
doubt,  the  latter  is  more  likely  to  occur  as  a  result  of  abscess  of  the  lung 
following  typhoid  fever,  than  it  is  after  abscess  following  simple  fibrinous 
pneumonia.  Whether  pneumonia  due  to  the  typhoid-bacillus  mav  be 
followed  by  the  formation  of  an  abscess  has  not  yet  been  established, 
but  it  is  entirely  probable,  as  the  typhoid-bacillus  is  well  known  to  be 
an  independent  pyogenic  agent. 

Symptoms  of  pulmonary  infarction,  which  consists  essentially 
in  the  development  of  an  acute  afebrile  consolidation,  with  hemoptysis, 
I  have  observed  repeatedly.  It  is  most  frequently  attributable  to  the 
detachment  of  marantic  thrombi  in  the  right  side  of  the  heart,  especially 
in  the  auricle  and  the  auricular  appendix.  Occasionally,  it  is  true,  the 
thrombus  is  derived  from  the  peripheral  veins.  In  stuporous  patients 
infarction  occurs  now  and  again  without  noteworthy  subjective  mani- 
festations ;  this  is  more  likely  to  be  the  case  since  such  patients  do  not 
expectorate  properly.  Most  frequently  acceleration  of  the  pulse  and  of 
respiratory  frequency  are  also  observed. 

While  infarction  occurs  in  some  cases  without  a  chill  and  without 
elevation  of  temperature,  in  others  it  sets  in  with  a  chill,  and  subse- 
quently the  temperature-curve  shows  septic  characteristics.  I  have 
observed  the  latter  kind  of  symptoms  especially  during  convalescence. 
These  symptoms  are  either  the  first  manifestations  of  a  pyemic  disorder 
or  are  due  to  emboli  in  the  course  of  such  a  disorder,  and  these  cases 
almost  always  pursue  an  unfavorable  course.  Under  the  most  favor- 
able conditions  these  lesions  are  followed  by  circumscribed  gangrene  of 
the  lungs  with  putrid  pleurisy  or  even  by  pneumothorax. 

Embolism  of  large  branches  of  the  pulmonary  artery,  which  fortu- 
nately .  is  rare  as  a  cause  of  sudden  death,  has  been  referred  to  (see 
Anatomy). 

Pulmonary  gangrene  appears  to  be  somewhat  more  frequent 
than  abscess  and  infarction  in  the  course  of  typhoid  fever.  Excluding 
the  cases  of  septic  embolism  just  referred  to,  pulmonaiy  gangrene  occurs 
most  frequently  as  the  termination  of  lobar  pneumonia  of  most  diverse 
origin,  especially  of  fibrinous  pneumonia.  The  condition  belongs  almost 
unexceptionally  among  the  complications  of  the  late  period,  since,  in 


256  TYPHOID  FEVER. 

addition    to    the    activity   of    the    special    micro-organisms    concerned, 

weakness  of  the  heart  and  general  emaciation  play  a  determining  role 

in  its  development. 

Id  1  case  I  observed  pneumonia  dir^secans  occur  in  the  sequence  of 
complicating  fiJ)rinou.s  pneumonia.  Fortunately  for  the  patient,  the  lesion 
ruptured  into  the  pleural  cavity,  and  the  sequestrum  was  discharged  into  it. 
A  resection  of  the  ribs  enabled  me  to  evacuate  the  consequent  putrid  empy- 
ema, together  with  the  gangrenous  portions  of  lung,  and  so  to  bring  about 
a  permanent  cure. 

The  cases  of  pulmonary  gangrene  resulting  from  the  aspiration  of 
decomposed  infectious  material,  derived  especially  from  the  mouth,  the 
nares,  and  the  pharynx,  are  also  important.  In  this  connection  a 
special  rdle  is  played,  according  to  my  experience,  by  the  more  super- 
ficial and  also  by  the  more  profound  ulcerative  form  of  purulent  ton- 
sillitis, and  especially  by  the  cases  of  laryngeal  ulceration  and  perichon- 
dritis.' In  deeply  stuporous  patients  such  conditions  remain  concealed 
from  the  physician  so  long  as  the  lesions  are  still  small,  and  become 
distinct  only  after  they  have  attained  a  certain  extent.  In  addition  to 
the  infectious  materials  mentioned,  aspiration  of  particles  of  food  is  also 
occasionally  the  cause  of  pneumonia  with  secondary  gangrene.  It  should 
not  be  forgotten  in  this  connection  that  aspiration  of  particles  even  of 
considerable  size  by  profoimdly  stuporous  jjatients  need  not  give  rise  at 
once  to  special  symptoms. 

I  have  observed  gangrene  of  almost  the  entire  lower  lobe  of  the  right 
lung  in  a  young  man,  the  cause  for  which  was  disclosed  only  upon  post- 
mortem examination  by  the  discovery  of  a  piece  of  decomposed  meat 
impacted  in  a  large  bronchus.  As  subsequently  appeared,  the  patient  had 
received  meat  surreptitiously  at  the  height  of  the  febrile  period,  while  he 
lay  in  a  stuporous  state,  and  the  time  when  a  portion  of  this  was  aspirated 
was  not  even  noted  by  the  neighboring  patients. 

Liebermeister  has  observed  cases  of  extensive  gangrene  of  the  lung 
without  antecedent  inflammation  of  the  organ  or  aspiration  of  foreign 
bodies,  and  he  has  attributed  the  condition  to  the  unusual  severity  of 
the  general  disturbance  of  nutrition.  In  view  of  the  large  experience 
of  this  observer,  these  cases  are  especially  noteworthy.  I  have,  fortu- 
nately, not  as  yet  encountered  such  cases. 

It  is  peculiar  that  Murchison  considered  gangrene  of  the  lung  an  extremely 
rare  complication  of  typhoid  fever.  He  saw  but  1  or  2  cases  which  followed 
pneumonia  in  the  course  of  typhoid  fever.  On  the  other  hand,  Liebermeister 
encountered  gangrene  in  14  among  230  fatal  cases.  It  is  quite  remarkable 
that  9  of  his  cases  occurred  in  the  course  of  three  months,  during  which 
the  hospital  was  greatly  overcrowded  and  it  was  impossible  to  provide  suita- 

'  See  also  Curschmann,  "Das  Fleckfieber, "  Ziemssen's  Handbuch  d.  kiln.  Med., 
Bd.  ii.,  3.  Aufl. 


SYMPTOMS  AND  COMPLICATIONS.  257 

ble  hygienic  conditions.  Griessinger  has  observed  gangrene  in  7  of  118  cases 
examined  post  mortem.  In  my  Leipsic  statistics  it  is  recorded  in  10  instances 
in  228  autopsies. 

That  the  frequency  of  the  pleurisy  is  variously  stated  by  different 
observers  is  probably  dependent  upon  different  interpretations  of  the 
term.  If  every  circumscribed  pleuritic  friction,  every  fibrinous  deposit 
upon  the  pleura  in  cases  of  lobar  and  lobular  pneumonia  or  other  focal 
disease  of  the  lung,  is  included  in  this  category,  then  pleurisy  is  almost 
as  frequent  a  disease  as  the  affections  of  the  pulmonary  parenchyma 
itself.  If,  however,  as  appears  to  be  more  practical,  principally  those 
cases  are  kept  in  mind  that  appear  more  or  less  independently,  espe- 
cially those  attended  with  the  development  of  moderate  or  large  effu- 
sions, then  the  condition  is  a  rare  occurrence.  When  it  occurs  at  all,  it 
is  a  manifestation  of  the  late  febrile  period  or  of  convalescence.  I  have 
exceptionally  encountered  pleurisy  during  the  first  week  which  was  such 
a  prominent  feature  of  the  case  that  the  designation  pleurotyphoid 
might  be  employed  in  the  same  way  that  French  investigators  ^  have 
used  pneumotyphoid  and  nephrotyphoid. 

In  a  number  of  cases  the  typhoid-bacillus  has  been  obtained  in  pure 
culture  from  the  serous  or  purulent  pleuritic  effusion,  and  its  primary 
etiologic  significance  in  a  number  of  these  cases  seems  fairly  well  estab- 
lished (see  section  on  Pathology).  Pleurisy  in  typhoid,  just  as  under 
other  circumstances,  is  probably  generally  secondary  to  affections  of  the 
lungs  or  of  other  contiguous  structures.  Cases  of  empyema  especially 
I  have  been  able  to  trace  to  antecedent  disease  of  the  lung.  A  number 
of  hemorrhagic  effusions  that  I  have  encountered  proved  to  be  tuber- 
culous. Certain  serous  effusions  possibly  have  a  more  independent 
origin ;  these,  however,  in  my  experience,  rarely  become  large,  and  there- 
fore but  exceptionally  demand  the  performance  of  thoracocentesis.  If 
direct  intervention  is  not  undertaken,  these  are  usually  of  longer  dura- 
tion in  cases  of  typhoid  fever  than  when  there  are  complications  of 
other  diseases.  Now  and  again,  it  is  true,  pleuritic  effusions  of  consid- 
erable size  disappear  rapidly  without  especial  interference.  Only  recently 
I  observed  in  a  student  suffering  from  typhoid  fever  a  large  left-sided, 
serofibrinous  effusion,  with  considerable  displacement  of  adjacent  organs, 
wMch,  nevertheless,  underwent  absorption  in  the  course  of  two  weeks.^ 

^  Lecorche  and  Talamon,  Etudes  med.,  1881.  Germain  See,  Die  einfachen  Lungen- 
krankheiten,  German  translation  by  Salomon.  Charrin  and  Eoger,  Soc.  med.  des 
hop.,  April,  1891.     Fernet,  Ibid.,  May,  1891. 

.*  It  may  be  considered  noteworthy  that  in  this  case  the  fluid  obtained  with  the 
exploratory  needle  exhibited  a  characteristic  agglutinating  effect  upon  bouillon-cultures 
of  typhoid-bacilli  in  the  same  degree  as  the  blood-serum  of  the  patient. 
17 


258  TYPHOID  FEVER. 

The  prognosis  of  serous  exudates  in  the  course  of  typhoid  fever  is, 
according  to  my  experience,  not  particularly  unfavorable.  That  it  has 
been  considered  so  upon  the  authority  of  Louis  is  due  to  the  fact  that 
the  individual  varieties  have  not  been  adequately  diiferentiated.  Natu- 
rally, pleurisy  is  of  far  graver  significance  if  purulent,  hemorrhagic,  or 
even  putrid  effusions  are  included  under  tluit  term. 

Pneumothorax  is  an  extremely  rare  complication  of  typhoid  fever, 
and  is  to  be  considered  merely  as  an  accidental  occurrence,  generally  in 
conjimction  with  disease-foci  in  the  lungs,  pulmonary  abscess,  pulmonary 
gangrene,  etc. 

Pulmonary  tuberculosis  bears  various  important  relations  to 
typhoid  fever  as  a  complication  and  a  sequel.  Even  earlier  writers  were 
aware  of  this.  Contrary  to  the  opinion  of  these  early  writers,  however, 
the  view  is  generally  held  at  the  present  day  that  when  tuberculous 
processes  appear  in  the  sequence  of  typhoid  fever,  the  condition  is  not 
due  to  an  intercurrent  disease,  but  almost  always  is  the  first  manifes- 
tation, or  represents  the  progression,  of  an  earlier  process  which  had 
hitherto  been  more  or  less  concealed. 

The  appearance  of  tuberculosis  is  confined  almost  exclusively  to  the 
later  period  of  typhoid  fever.  Even  in  the  latter  half  of  the  febrile 
period  it  is  less  common  than  during  convalescence,  and  in  some  cases 
the  symptoms  become  distinct  only  after  the  patients  have  left  their 
beds  and  are  apparently  convalescent.  Cases  of  the  latter  character 
led  earlier  writers  to  believe  that  typhoid  fever  might  terminate  in 
pidmonary  tuberculosis  by  the  direct  caseation  of  inflammatory  foci 
developed  during  its  course. 

Tuberculosis  occurs  in  various  forms  in  the  course  of  typhoid  fever. 
I  have  observed  miliaiy  tuberculosis  as  a  complication  only  with  rela- 
tive rarit}',  and  then  especially  during  the  last  part  of  the  febrile  period 
or  the  first  part  of  convalescence.  Under  such  circumstances  there  is 
danger  of  confusing  this  condition  with  intercurrent  cerebrospinal  men- 
ingitis, which,  as  experience  has  shown,  may  occur  at  this  time  (see 
Nervous  System).  Noting  the  considerable  acceleration  of  respiratory 
frequency  which  attends  the  nervous  manifestation,  careful  observation 
of  the  changes  in  the  physical  conditions  of  the  lungs  and  examina- 
tion of  the  eye-grounds  will  help  to  clear  up  the  situation.  Positive 
results  from  examination  of  the  sputum  under  such  circumstances  are 
less  to  be  expected  than  when  miliary  tuberculosis  occurs  independently. 
On  the  other  hand,  positive  results  are  more  to  be  expected  in  the 
extremely  rare  cases  of  mixed  infections  of  fibrinous  pneumonia  and 
tuberculosis  in  cases  of  typhoid  fever,  which  exhibit  nothing  distinctive 


SYMPTOMS  AND  COMPLICATIONS.  259 

from  the  physical-diagnostic  standpoint.  In  1  such  case  I  was  able 
to  demonstrate  tubercle-bacilli  in  moderate  number  in  the  sputum,  in 
addition  to  the  Frankel-Weichselbaum  diplococci.  Exceptionally,  I 
have  observed  the  tuberculous  process  to  appear  in  the  form  of  acute 
or  subacute  peribronchitis,  A  case  of  this  kind  under  my  observation 
began  as  early  as  the  third  week ;  2  others — and  this  appears  to  be 
the  more  usual — during  convalescence.  As  direct  examination  of  the 
lungs  under  such  circumstances,  particularly  at  the  beginning,  yields 
only  uncertain  results,  such  cases  may  be  the  source  for  various  errors, 
especially  the  assumption  of  simple  recrudescences  or  relapses.  Such 
patients  also  expectorate  but  little,  if  at  all,  and  the  sputum,  in  my 
experience,  rarely  contains  bacilli.  Of  diagnostic  importance  on  the  one 
hand  are  the  increase  and  persistence  of  the  fever,  without  enlargement 
of  the  spleen  or  presence  of  fresh  roseolse,  and,  on  the  other  hand,  con- 
siderable rapid  increase  and  extension  of  the  bronchitic  symptoms,  with 
pulmonary  emphysema,  subjective  and  objective  dyspnea,  cyanosis,  and 
sweats. 

Quite  rare  also,  but  important  on  account  of  the  danger  of  confu- 
sion with  other  varieties  of  lobar  pneumonia  occurring  in  the  course  of 
typhoid  fever,  is  acute  tuberculous  infiltration  of  considerable  portions 
of  the  lungs,  especially  of  the  lower  lobes.  This  condition  may  set  in 
with  a  chill,  pain  in  the  side,  severe  cough,  and  blood-tinged  sputum, 
just  as  do  other  forms  of  pneumonia.  Nevertheless,  the  persistence  of 
the  fever  and  the  imperfect  resolution  will  soon  arouse  suspicion,  which 
becomes  converted  into  sad  certainty  by  the  demon.stration  of  elastic 
fibers  and  tubercle-bacilli  in  the  abundant  mucopurulent  sputum,  and 
probably  also  by  the  physical  signs  of  breaking  down  of  the  pulmonary 
tissue. 

The  onset,  the  first  symptoms,  and  the  course  of  subacute  or  chronic 
tuberculosis  of  the  ordinary  kind  compUcating  typhoid  fever  are  differ- 
ent in  every  individual  case,  and  are  to  be  valued  in  diagnosis  and 
prognosis  accordingly.  Fortunately,  the  association  is  by  no  means 
frequent,  and  the  outlook  for  checking  the  tuberculous  process  is,  in 
my  experience,  not  so  gloomy  as  some  clinicians  believe. 

NERVOUS  SYSTEM  AND  ORGANS  OF  SPEQAL  SENSE. 
Typhoid  fever  is,  not  without  cause,  known  popularly  as  ners^ous 
fever.  The  physician  must  admit  that  this  designation  is  appropriate 
in  view  of  the  prominent  nervous  symptoms  of  the  disease.  In  fact,  the 
disturbances  on  the  part  of  the  nervous  system  in  cases  of  typhoid  fever 
are  especially  frequent  and  varied.     They  occur  from  the  earliest  period 


260  TYPHOID  FEVER. 

throughout  all  stages,  and  threaten  the  patient  far  into  convalescence. 
Even  in  the  period  of  incubation  and  in  the  initial  stage  nervous  symp- 
toms are  marked.  These  include  general  malaise,  mental  depression, 
dragging  sensations  and  cutting  pains  in  the  extremities  in  the  course  of 
the  large  nerve-trunks,  sacral  pain,  vertigo,  roaring  in  the  ears,  and 
headache, 

Pleadache  is  probably  one  of  the  most  constant  symptoms  of  the 
initial  period — far  more  constant  than  the  sacral  pain.  It  is  at  times 
referred  to  the  forehead  or  to  the  occiput,  less  commonly  to  one  side  of 
the  head.  At  other  times  it  exhibits  an  intense  stabbing,  boring  char- 
acter. At  still  other  times — and  this  is  true  of  the  majority  of  cases 
— it  is  described  as  a  dull,  heavy  pressure,  or  is  like  a  band  tied  about 
the  head.  True  neuralgic  pains  as  an  initial  symptom  of  typhoid  fever 
are  worthy  of  mention,  especially  pains  in  the  distribution  of  the  supra- 
orbital, infra-orbital,  and  occipital  nerves,'  although  in  my  experience 
they  are  quite  rare. 

Toward  the  end  of  the  first  or  at  the  beginning  of  the  second  week, 
in  cases  of  moderate  or  severe  course,  the  complaint  of  headache  and 
the  remaining  subjective  nervous  symptoms  generally  lessen.  The 
patient,  now  becomuig  stupid,  is  no  longer  capable  of  appreciating  his 
condition,  and  his  statements  caimot  be  relied  upon.  It  is  even  urgently 
advisable,  when  a  typhoid  patient  still  complains  o-f  headache  or  vertigo 
at  the  height  or  toward  the  end  of  the  febrile  period,  or  begins  to  make 
new  complaints  of  headache  at  that  time,  that  attention  be  directed  to 
complications,  especially  meningitis  and  other  intracranial  alterations. 
In  the  first  stage  of  the  disease,  almost  coincidently  with  the  com- 
plaint of  headache,  there  is  generally  complaint  of  sleeplessness  also. 
This  becomes  less  pronounced  with  increasing  stupor.  Naturally,  a 
sharp  distinction  must  always  be  made  between  sopor  and  sleep  in  a 
sick  person.  Every  experienced  clinician  knows  that  a  stupid  patient 
may  actually  sleep  or  may  be  sleepless.  On  further  examination  it  may 
be  found  that  the  sleeplessness,  although  the  patient  may  no  longer  com- 
plain of  it,  persists  in  varying  degree  throughout  the  entire  febrile  stage. 
The  majority  of  patients  sleep,  it  at  all,  for  only  short  periods,  with 
frequent  interruptions.  The  relatively  early  occurrence  of  profound, 
long  sleep  is  a  favorable  sign. 

Toward  the  end  of  the  first  week  the  severe  and  the  moderately 

severe  cases   almost  regularly   begin  to  exhibit  that  condition  of  the 

ner\'-ous  system  which  is  designated  as  the  actual  typhoidal  state ;  which 

is  attended  with  obtunding  of  consciousness  and  dulling  of  the  special 

*  See  Q.  Eosenbach,  Deutsch.  Arch.  f.  klin.  Med..,  Bd.  xvii. 


SYMPTOMS  AND  COMPLWATTONS.  261 

senses.  The  complaints  lessen  gradually,  the  interest  of  the  patient  in 
his  surroundings  diminishes,  and  the  desire  for  food  and  drink  becomes 
progressively  less.  The  patient  lies  in  an  apathetic  state  in  a  relaxed 
dorsal  decubitus,  but  still  reacts  sluggishly  to  loud  speaking,  to  ques- 
tions, and  to  active  sensory  impressions.  His  statements  are  still  fairly 
rational,  but  even  slight  demands  upon  mental  activity  are  speedily 
followed  by  fatigue.  After  making  brief  replies,  he  relapses  into  his 
stuporous  condition,  in  which  he  is  likely  to  be  annoyed  by  dream-like 
hallucinations,  which  constantly  reappear  as  soon  as  the  eyes  are  closed, 
or  even  during  the  half-waking  state. 

With  the  progress  of  the  disease,  generally  at  the  beginning  or  the 
middle  of  the  second  week,  in  severe  cases  or  in  irritable  individuals 
earlier,  the  dream-like  hallucinations  become  transformed  toward  even- 
ing and  during  the  night  into  actual  delirium.  This  is  generally  not 
violent  and  aggressive  at  first,  but  the  patients  rather  work  and  talk 
aimlessly  in  a  quiet  manner  concerning  matters  related  to  their  usual 
pursuits  and  experiences,  being  influenced  immediately  and  markedly 
by  auditory,  visual,  and  sensory  impressions.  At  times  the  hallucina- 
tions are  of  an  alarming  nature.  Some  patients  complain  of  nightmare- 
like conditions,  while  others  cannot  get  rid  of  peculiar  hallucinations 
with  regard  to  certain  parts  of  the  body.  They  have  an  impression 
that  the  head  or  entire  members  are  shrunken  or  have  disappeared,  or, 
on  the  contrary,  have  grown  to  enormous  size  and  then  have  become 
moderate  in  size. 

Some  patients  exhibit  a  tendency  to  get  out  of  bed.  Under  such 
circumstances  they  rarely  injure  themselves  or  others.  Wild,  dangerous 
delirium,  with  threats  against  attendants,  attempts  at  flight,  etc.,  such 
as  are  quite  commonly  observed  in  cases  of  typhus  fever  and  variola, 
are  very  much  less  frequent  in  cases  of  typhoid  fever.  In  drinkers  the 
mental  disturbance  generally  resembles  that  seen  in  alcoholic  delirium. 
True  delirium  tremens,  such  as  almost  always  occurs  when  hard  drinkers 
are  attacked  with  the  other  severe  infectious  diseases,  as,  for  instance, 
fibrinous  pneumonia  and  erysipelas,  and  which  sets  in  with  rapid  eleva- 
tion of  temperature,  occurs  with  relative  rarity  in  typhoid  fever.  At 
the  middle  or  end  of  the  second  week  the  delirium,  which  at  first  was 
noticeable  only  toward  evenmg  or  during  the  night,  begins  to  persist 
also  during  the  day.  The  patients  can  still  at  this  time  be  awakened  at 
times,  and  their  attention  attracted,  and  temporarily  even  be  convinced 
of  the  groundlessness  of  their  excitement.  Soon,  however,  the  abnor- 
mal delusions  and  hallucinations  become  more  and  more  fixed  and  con- 
sciousness more  obscure ;  and  the  patients  enter  upon  a  state  in  which 


262  TYPHOID  FEVER. 

tbev  take  no  notice  of  their  surroimdintjs,  and  are  day  and  night  in  a 
ch-eamy  state,  unconscious  of  their  condition.  The  features  are  relaxed, 
expressionless,  even  somewhat  drawn  ;  the  eyes  are  wholly  or  half-open, 
stare  directly  forward,  and  are  no  longer  fixed  on  any  definite  object. 
The  patients  murmur  and  are  quietly  restless,  but  bect)me  more  actively 
so  toward  evening  and  night.  In  uncomplicated  cases  which  are  not 
of  extreme  severity  this  condition  persists  into  the  third  week,  and  even 
to  the  end  of  this  week,  then,  with  the  beginning  of  convalescence, 
imdergoing  gradual  improvement.  The  patients  now  become  quieter, 
and  again  at  times  conscious ;  they  begin  to  sleep,  and  with  a  reduction 
of  the  temperature  to  the  normal  or  below,  often  even  during  the  stage 
of  steep  curves,  they  become  completely  rational,  except  during  sleep, 
especially  at  night,  when  dreams  occur  that  are  forgotten  with  difficulty. 
It  can  readily  be  understood  that  the  disturbances  above  described 
exhibit  the  most  diverse  variations  in  accordance  with  the  severity 
of  the  attack,  and  especially  in  accordance  with  the  temperament  of 
the  patient.  Irritable  persons,  children,  women,  and  delicately  con- 
stituted men  naturally  exhibit  marked  disturbance  of  consciousness, 
when  those  of  strong  nerves  are  wholly  unaifected.  In  extremely 
severe  cases,  however,  the  most  robust  individuals  may  enter,  even 
during  the  first  days,  into  a  state  of  delirium,  which  soon,  occasionally 
as  early  as  the  beginning  or  the  middle  of  the  second  week,  passes  into 
deep  sopor  and  into  coma.  Such  patients  exhibit  the  appearance  of 
most  profound  intoxication,  with  paralytic  relaxation  of  the  entire  body 
— an  open  mouth  with  dependent  jaw  and  dry,  encrusted  mucous  mem- 
brane of  lips,  tongue,  and  mouth,  and  labored,  stertorous  breathing. 
They  cannot  be  completely  awakened,  and  they  can  only  at  times,  and 
then  by  active  interference,  be  induced  to  make  transitory,  indistinct 
statements.  Even  the  swallowing  reflex  can  be  elicited  only  with 
difficulty.  The  urine  and  the  stools  are  generally  voided  in  bed.  This 
condition  may,  in  severe  cases,  continue  throughout  the  third  week,  and 
it  may  persist  even  longer,  under  which  circumstances  it  is  especially 
to  be  mentioned  that  the  gravity  of  the  general  condition  is  by  no  means 
constantly  attended  with  corresponding  elevation  of  temperature.  On 
the  contrary,  remarkably  low  temperature  with  a  curve  of  most  irregular 
course  is  at  times  found  in  association  with  a  most  serious  and  most 
alarming  general  condition. 

With  the  more  profound  conditions  of  stupor,  peculiar  motor  mani- 
festations of  most  varied  character  and  severity,  from  the  simplest 
tremor  to  spasmodic  twitchings  and  convulsions,  are  also  quite  commonly 
associated.     This  does  not  imply  that  such  motor  disturbances  do  not 


SYMPTOMS  AND  COMPLICATIONS.  263 

also  occur  in  cases  of  moderate  and  mild  course.  They  are  merely 
more  frequent  and  more  pronounced  in  the  severe  cases,  but  they  vary 
with  regard  to  their  character,  duration,  and  extent,  in  accordance  with 
the  individual  irritability. 

Simple  tremor  occurs  in  debilitated,  irritable  persons  quite  commonly 
as  early  as  the  initial  stage.  This  is  the  case  also  in  more  robust  alco- 
holic individuals.  More  intense  motor  disturbances  generally  appear  as 
transitory  manifestations  in  the  later  febrile  stage  in  the  lighter  and 
moderate  cases.  They  occur  early  and  persistently  almost  solely  in  the 
severe  cases,  and,  as  a  result,  acquire  a  degree  of  prognostic  significance 
not  to  be  underrated.  Among  these  more  severe  disturbances  picking  at 
the  clothing  (floctitation)  is  first  to  be  mentioned,  as  it  probably  is  the 
mildest  and  least  significant  from  the  prognostic  point  of  view.  The 
soporose  patient,  lying  quietly,  moving  the  lips  uninterruptedly,  mur- 
muring LQCoherently,  pulls  constantly  with  tremulous  hands  at  the 
clothing  and  bed-covering.  In  fact,  the  analogy  with  the  pulling  of 
wool,  the  plucking  of  down,  and  the  like,  is  most  appropriate.  At 
times  the  tremulous,  jerky  movements  exhibit  peculiarities  suggestive  of 
the  previous  occupation  of  the  patient.  However  marked  the  manifesta- 
tions may  be  in  the  arms  and  the  hands,  there  is  often  no  particular  move- 
ment in  the  lower  extremities,  or  at  most  a  certain  amount  of  tremor. 

With  the  progress  of  the  disease,  and  in  serious  cases,  the  tremor 
and  floctitation  are  often  soon  associated  with  rather  violent  muscular 
twitching,  which  is  also  more  marked  in  the  trunk  and  the  upper 
extremities  than  in  the  lower  extremities.  This  may  displace  the  true 
tremor  entirely,  and  appears  especially  in  the  forearms  and  the  hands, 
as  a  jerking  prominence  of  the  muscles  and  tendons  and  the  related 
fingers — tendon-jerking  (subsultus  tendinum).  In  some  cases,  espe- 
cially in  patients  who  are  exceedingly  restless  and  have  vivid  dreams, 
more  or  less  marked  twitching  throughout  entire  muscle-groups  may 
become  associated  with  floctitation  and  subsultus,  especially  when  a 
purposeful  movement  is  attempted.  This  is  then  highly  suggestive  of 
true  intention-tremor.  At  times  all  these  manifestations  occur  over 
the  trunk,  the  four  extremities,  and  even  the  face,  naturally  always  with 
a  preponderance  in  the  arms,  so  that  the  clinical  pictures  acquire  close 
resemblance  to  a  severe  choreic  condition.  Such  phenomena  were 
obviously  in  the  minds  of  those  writers  who — in  my  opinion  incorrectly 
— spoke  of  a  combination  of  typhoid  fever  with  true  chorea  at  the 

'  The  occurrence  of  true  chorea  minor  during  convalescence,  as  has  been  observed 
repeatedly  by  Barthez  and  Killiet,  and  others,  and  also  by  myself,  naturally  has 
nothins;  to  do  with  the  condition  under  consideration. 


264  TYPHOID  FEVER. 

height  of  the  febrile  stage.*  The  further  supervention  in  aduks  of 
trismus  and  a  tetanus-like  condition — grinding  of  the  teeth,  tonic  con- 
tracture of  the  extremities  and  of  the  muscles  of  the  back  and  the  naj^e 
of  the  neck — is  quite  alarming  and,  fortunately,  not  very  frequent. 
Such  attacks  are  more  frequent  and  of  slighter  significance  in  irritable 
children.  In  adults  they  are  the  expression  either  of  a  most  profound 
toxic  action  upon  the  central  nervous  system  or  of  es])ec'ially  severe 
complications,  among  which  meningitis,  miliary  tuberculosis,  and  septic 
or  uremic  conditions  are  especially  to  be  mentioned.  In  children  I 
have  observed  general  convulsions  without  severe  complications,  and 
not  rarely  the  cases  terminated  in  recovery.  In  adults  the}^  are,  in  any 
event,  extremely  rare.  If  they  occurred,  I  should  invariably  suspect 
complications,  or  raise  the  question  whether  the  diagnosis  of  typhoid 
fever  is  still  to  be  adhered  to. 

Because  of  the  variability  and  the  combinations  of  cerebral  and 
spinal  disturbances,  especially  of  the  abnormal  motor  manifestations 
and  the  psychic  symptoms  of  dej^ression  or  excitement,  the  earlier  phy- 
sicians distinguished  a  number  of  different  varieties  of  typhoid  fever, 
to  which,  naturally,  only  superficial  significance  can  be  attached.  The 
best  kno^vn  of  these  varieties  are  the  following :  "  Febris  nervosa 
stupida,"  that  variety  m  which  the  patients  lie  in  a  soporose  state — 
murmuring,  tremulous,  with  floctitation ;  and  "  febris  nervosa  versatilis," 
in  which,  as  the  name  implies,  the  disturbance  of  consciousness  is 
associated  with  especial  restlessness,  subsultus  tendmum,  choreiform 
twitching,  active  delirium,  up  to  conditions  of  most  marked  excitement 
with  attempts  at  flight  and  violence. 

It  has  been  pointed  out,  and  it  must  here  be  emphasized  agam,  that 
the  conditions  hitherto  described  are,  as  a  rule,  not  dependent  upon 
anatomically  demonstrable  lesions.  I  have  noted  the  condition  of  the 
brain  at  niunerous  autopsies  in  various  stages  of  typhoid  fever.  There 
is  present  generally  some  serous  infiltration  of  the  cerebral  tissue, 
rarely  marked  hyperemia  or  anemia.  Especially  is  there  no  confirma- 
tion for  the  statement  which  one  hears  and  reads  now  and  then  that 
conditions  of  excitement  are  associated  with  hyperemia,  while  the 
"  febris  nervosa  stupida "  is  more  frequently  dependent  upon  anemia 
or  serous  infiltration  of  the  substance  of  the  brain.  Marked  cerebral 
edema,  with  more  or  less  marked  dropsy  of  the  ventricles,  which  is  so 
often  made  responsible  for  profound  comatose  states,  I  have  rarely 
encountered,  and  it  was  then  by  no  means  always  associated  during 
life  witli  profound  stupor. 

The  opinion  of  Liebermeister,  that  the  febrile  temperature    alone 


SYMPTOMS  AND  COMPLICATIONS,  265 

explained  the  severe  general  disturbances  on  the  part  of  the  central  nervous 
system  which  have  hitherto  been  discussed,  has  not  proved  entirely 
satisfactory.  It  is  true  that  quite  generally  the  previously  impaired 
intelligence  is  observed  to  improve  and  return  in  the  sequence  of  cold 
baths,  and  also  that  certain  complications  attended  with  reduction  in 
temperature,  as,  for  instance,  the  profuse  intestinal  hemorrhages  from 
the  bowel,  already  mentioned,  have  the  same  effect ;  but,  upon  the  other 
hand,  the  character  and  the  manifestations  of  cerebral  disturlmnces, 
especially  the  varying  degree  of  stupor,  do  not  correspond  with  the 
height  and  the  intensity  of  the  fever.  On  the  contrary,  the  most  pro- 
found cerebral  disturbances  may  occur  with  quite  low  temperature ; 
while  cases  of  afebrile  typhoid  fever  are  at  times  attended  with  symp- 
toms of  most  pronounced  nervous  depression. 

Another  factor,  namely,  the  action  of  the  toxins  upon  the  central 
nervous  system,  is  far  more  important  than  the  temperature.  This 
factor  alone,  however,  does  not  determine  the  character  and  the  severity 
of  the  disturbances  in  question.  These  behave  and  are  modified  rather 
in  accordance  with  the  remaining,  especially  the  individual,  conditions ; 
on  the  one  hand,  in  accordance  with  age,  sex,  constitution,  heredity,  and 
antecedent  diseases ;  and,  on  the  other  hand,  in  accordance  with  the 
general  condition  of  the  patient  or  that  of  individual  organs  as  influ- 
enced by  the  typhoid  disease  and  by  its  stage. 

With  reference  to  age  and  sex,  it  can  readily  be  understood  that 
women,  children,  and  the  aged  react  differently  than  robust,  previously 
healthy  men,  if  all  are  exposed  to  the  action  of  similar  influences  upon 
the  central  nervous  system.  Anemic  and  plethoric  individuals  also  will 
exhibit  different  manifestations.  Among  conditions  present  antecedent 
to  the  attack  of  typhoid  fever  which  predispose  to  profound  nervous 
disturbances  are  especially  neurasthenia,  hysteria,  and  mental  or  physi- 
cal injuries  of  long  standing,  and,  above  all,  emotional  disturbances  and 
conditions  of  depression,  bodily  overexertion,  excesses  in  food  and  toxic 
substances,  such  as  morphin,  bromids,  chloral,  coffee,  tea,  and  especially 
alcohol. 

Psychoses. — Although  the  actual  mental  disturbances  occurring 
in  the  course  of  typhoid  fever  are  often  directly  related  to  the  febrile 
delirium,  and  are  often  not  sharply  separable  from  it,  and  frequently 
even  appear  to  arise  out  of  it,  nevertheless  the  character  and  peculiarity 
of  their  onset  and  course  render  necessary  their  special  consideration. 

At  times  as  early  as  the  second,  more  frequently  in  the  third  week, 
peculiar  illusions  and  delusions  and  associated  abnormal  acts  stand  out 
prominently  in  some  patients  from  among  the  general  symptoms  of  the 


266  TYPHOID  FEVER. 

febrile  stupor,  and  are  worthy  of  special  cousideration  by  reason  of  their 
independence  and  })eculiarity.  In  part  they  soon  subside  with  the 
remauiing  febrile  symptoms  of  the  attack  of  typhoid  fever,  in  part  they 
persist  independently  and  obstinately  for  a  variable  length  of  time  after 
defervescence,  and  even  after  convalescence  has  been  completed.  As 
has  already  been  pointed  out  with  regard  to  the  ordinaiy  forms  of 
febrile  delirium,  the  mentiil  conditions  under  these  circumstances  are 
very  rarely  states  of  excitement  with  aggressive  tendencies,  but  more 
frequently  consist  in  acts  and  delusions  that  exhibit  the  character  of 
mental  depression,  of  fear  or  anxiety,  with  or  without  hallucinations. 
One  patient  may  occupy  himself  with  groundless  self-accusation,  and 
laments  a  life  which,  from  a  religious  or  other  standpoint,  has  been 
wasted ;  another  may  hear  voices  or  see  figures  that  depress,  persecute, 
or  threaten  him ;  and  still  another  may  lie  rigidly  in  bed,  not  eating  or 
drinking  or  reacting  at  all,  believing  himself  motionless  or  even  dead. 
Still  others  believe  they  have  amassed  great  fortunes,  which  they  fear 
they  may  lose,  or  they  search  for  and  lament  the  loss  of  valuables. 

Although,  as  has  been  mentioned,  these  delusions  often  disappear 
with  deferv'escence,  nevertheless  they  frequently  persist  thereafter  and 
become  fixed  far  more  frequently  than  in  the  sequence  of  most  other 
acute  infectious  diseases.  The  mental  depression  and  confusion,  or  only 
certain  morbid  conceptions,  may  then  persist  in  the  presence  of  an 
otherwise  apparently  intact  sensorium  into  the  period  of  convalescence, 
or  even  extend  far  beyond  it.  Some  patients,  after  they  have  been  out  of 
bed  for  a  long  time  and  appreciate  the  nature  of  the  disease  from  which 
they  have  recovered  and  the  delirium  that  was  associated  with  it,  are 
still  unable  to  free  themselves  from  certain  imperative  ideas.  In  other 
respects  they  make  an  impression  of  mental  quietude  and  intelligence, 
and  themselves  admit  that  on  one  point  thought  and  speech  are  morbid, 
but  they  are  constantly  irresistibly  impelled  thereto. 

Thus,  I  observed  a  young  journeyman  tailor  who  was  unable  to  free 
himself  from  the  belief  that  a  benevolent  woman  had  presented  him  with  a 
good  deal  of  money,  and  had  concealed  it  for  him  behind  a  closet  in  the 
ward.  Long  after  the  patient  had  gotten  out  of  bed  this  thought  could  only 
temporarily  be  dispelled.  Even  after  he  had  improved  remarkably  in 
physical  condition,  and  mentally  appeared  entirely  clear,  he  was  only  half- 
convinced  with  regard  to  his  delusion.  He  had  some  diffidence  in  speaking 
of  it,  but  every  now  and  then,  in  an  unwatched  moment,  he  glanced  long- 
ingly toward  the  corner  occupied  by  the  promising  chest.  In  another  case,  a 
servant-girl,  eighteen  years  old,  during  the  febrile  stage  was  possessed  by 
the  delusion  that  she  had  been  visited  by  her  uncle,  who  suddenly  became 
so  greatly  distended  as  to  burst.  While  during  the  febrile  stage  she  lamented 
bitterly  the  fate  of  her  uncle,  she  laughed  during  convalescence   at  the 


SYMPTOMS  AND  COMPLICATIONS.  267 

thought  of  his  peculiar  method  of  dying,  but  even  after  she  had  been  free 
from  fever  and  out  of  bed  for  weeks  she  could  not  rid  herself  of  the  idea 
that  he  had  at  least  died.  Another  patient,  a  stone-setter,  forty  years  old, 
became  incessantly  excited  during  the  last  week  of  the  fever  concerning  his 
child,  which  he  thought  had  been  stolen  from  him  by  neighbors,  and  had 
been  cut  up  and  burned  upon  a  sand-heap.  The  harassing  thought  followed 
him  into  convalescence.  Attempts  were  made  without  avail  to  relieve  him 
of  this  delusion  by  bringing  the  child,  which  was  entirely  well,  to  him.  A 
few  hours  after  the  departure  of  the  child  the  delusion  would  return. 

In  addition  to  the  form  of  psychic  disturbances  just  mentioned, 
those  occurring  in  individuals  who  have  hysteric  tendencies  deserve 
special  mention.  I  have  observed,  principally  in  young  vv^omen  and 
men,  conditions  of  more  or  less  marked  catalepsy  occurring  as  early  as 
the  second  week,  and  from  this  time  on  to  the  period  of  defervescence — 
only  exceptionally  in  the  afebrile  period.  The  patients  lie  motionless 
and  completely  unresponsive,  apparently  unconscious,  with  eyes  wide 
open,  without  sleeping  day  or  night,  taking  no  food  or  drink,  and 
voiding  the  urine  and  stools  in  bed.  Such  cases  are  considered  by  the 
inexperienced  as  of  especial  severity ;  and  the  most  profound  typhoid 
intoxication  with  deepest  coma,  or  even  meningitis,  or  extensive  men- 
ingeal hemorrhage,  is  assumed  to  exist.  If,  however,  such  patients  are 
observed  more  critically,  it  will  be  found  that  they  react  to  very  strong 
auditory  and  visual  stimuli,  even  to  a  loud  call,  with  a  sigh,  increased 
frequency  of  winking,  co-ordinated  voluntary  movements  of  the  eyes, 
sudden  acceleration  of  pulse-frequency,  or  the  development  of  an  emo- 
tional erythema.  One  can  see  that  the  patients,  though  conscious,  have 
their  powers  of  expression  greatly  inhibited,  and  lie  in  a  state  of  plastic 
flexibility  which  is  one  of  the  most  certain  signs  of  the  existence  of  the 
cataleptic  state.  After  this  clinical  picture  has  been  seen  a  few  times  in 
its  most  characteristic  form,  it  will  become  apparent  that  slighter  degrees 
of  hysteric  stupor,  with  more  or  less  marked  catalepsy  and  plastic 
flexibility  of  the  muscles,  are  not  at  all  rare  in  predisposed  individuals. 
Far  less  common  than  the  foregoing  disturbances  are,  in  my  experience, 
cases  of  actual  hysteric  insanity.  In  those  patients  in  whom  I  have 
observed  this  condition  it  did  not  occur  during  the  febrile  period,  but 
in  the  earlier  stage  of  convalescence. 

Among  4000  cases  of  typhoid  fever,  I  have  observed  more  or  less  well- 
developed  psychoses  at  the  height  of  the  fever  or  during  convalescence  in 
42.  In  35  cases  the  mental  disturbance  occurred  during  the  febrile  stage, 
in  2  during  the  period  of  irregular  temperature,  and  in  5  during  conva- 
lescence. These  patients  were  exclusively  adults,  and  women  were  more  fre- 
quently affected  than  men.  I  noted  27  of  the  former  and  15  of  the  latter. 
In  32  of  the  cases  states  of  melancholia  or  quiet  delirium  were  present,  with 


268  TYPHOID  FEVER. 

or  without  hallucinatious ;  while  iu  the  remainder,  conditions  of  more  or  less 
marked  excitement  and  even  maniacal  states  were  observed.  With  regard 
to  hysteropsychic  disturbances,  and  especially  the  cataleptic  variety,  which 
I  have  observed  far  more  frequently,  1  have,  unfortunately,  no  statistics. 

Owing  to  the  field  of  my  activity,  the  conditious  that  I  have  hitherto 
been  able  to  describe  from  my  personal  observation  belong  almost  exclu- 
sively to  the  period  of  the  actual  disease  and  the  patient's  residence  in 
the  hospital  up  to  the  time  of  complete  recovery  and  dismissal.  Alien- 
ists are,  however,  famiKar  with  cases  of  mental  derangement  that  develop 
much  later,  but  which  occur  undoubtedly  in  consequence  of  the  attack 
of  typhoid  fever.  These  cases  following  typhoid  fever  are  quite  common 
as  compared  with  those  following  the  other  infectious  diseases,  and  they 
often  exhibit  marked  severity  and  obstinacy  and  protracted  duration. 
Under  these  circumstances  the  condition  is  usually  one  of  depression  or 
melancholia,  with  self-accusation,  fear  and  anxiety,  stupor,  and  often 
hallucinations ;  though  not  much  less  common  are  quieter  conditions, 
with  peculiar  ideas,  especially  delusions  of  grandeur ;  and  more  rarely, 
commonly,  conditions  of  excitement  up  to  the  point  of  mania  or  acute 
dementia  (Krafft-Ebing  ^). 

The  prognosis  of  typhoid  psychoses  appears  in  general  to  be  favor- 
able. Of  the  cases  under  my  observation,  previously  mentioned,  which 
developed  during  the  febrile  period  and  early  in  convalescence,  only  2 
persisted  beyond  the  period  of  convalescence;  the  one  terminated  in 
recovery  after  six  months,  the  other,  after  nine  months.  The  severer 
psychoses  also,  which  necessitate  treatment  in  hospitals  for  the  insane, 
appear  in  general  to  pursue  a  not  unfavorable  course.  According  to 
Krafft-Ebing,  the  prognosis  is  almost  always  favorable  in  conditions 
of  quiet  delirium.  Quiet  or  even  stuporous  melancholia  may  last  for 
months,  but  in  65  per  cent,  of  the  cases  it  terminates  in  recovery ; 
recovery  from  conditions  of  maniacal  excitement  and  from  acute  dementia 
occurs  in  from  50  to  65  per  cent,  of  the  cases. 

Before  leaving  this  section  it  appears  worthy  of  mention  that  in 
exceedingly  rare  cases  marked  psychic  disturbances  may  be  present  at 
the  very  onset  of  the  attack  of  typhoid  fever,  even  as  early  as  the  first 
day,  or,  at  least,  at  the  beginning  or  the  middle  of  the  first  week,  and 
they  may  then  exhibit  the  characteristics  of  an  independent  disorder. 
Such  cases  are  well  calculated  to  give  rise  at  first  to  error  in  diagnosis. 
I  have  observed  2  cases  in  which  patients  of  this  kind  were  at  once 
sent  to  a  hospital  for  the  insane,  where  the  true  nature  of  the  disease 
first  became  manifest  when,  after  the  lapse  of  eight  and  twelve  days, 
^  See  the  text-books  on  psychiatry  by  Kraeplin,  Kraflft-Ebing,  and  others. 


SYMPTOMS  AND  CO 31  PLICATIONS.  269 

respectively,  enlargement  of  the  spleen,  diarrhea,  and  distinct  roseolse 
made  their  appearance. 

The  fact  that  the  previously  insane,  if  exposed  to  the  possibility  of 
infection,  are  attacked  by  typhoid  fever  almost  as  frequently  as  healthy 
individuals,  should  likewise  be  considered  in  tins  connection.  Under 
such  circumstances  the  course  and  termination  of  the  disease  vary,  as  in 
other  cases,  m  accordance  with  the  constitution  of  the  patient,  the 
severity  of  the  infection,  and  such  complications  as  may  be  present. 
It  has  been  stated  that  in  a  number  of  such  cases  after  recovery  had 
taken  place  from  the  attack  of  typhoid  fever  considerable  unprovement, 
or  even  complete  recovery  from  the  psychosis,  occurred.  Unfortunately, 
this  is  the  exception  and  not  the  rule. 

Nervous  Disturbances  with  Demonstrable  Organic 
I^esions. — Although  the  affections  of  the  nervous  system  thus  far 
described  have  been  classed  separately  from  a  number  of  others  which 
are  known  to  be  dependent  upon  macroscopically  and  microscopically 
demonstrable  anatomic  lesions,  it  will  readily  be  understood  that  dis- 
tinction is  not  final,  but  is  only  an  expression  of  the  present  state  of 
our  knowledge.  Without  doubt  the  so-called  functional  disturbances 
will  also  in  the  course  of  time  become  more  and  more  accessible  to 
anatomic  investigation. 

Alterations  in  the  Meninges. — Among  these,  meningitis,  which 
is  usually  not  confined  to  the  brain  alone,  but  far  more  frequently  is 
cerebrospinal  in  distribution,  should  be  mentioned  first  on  account  of 
its  importance.  During  certain  epidemics  of  typhoid  fever  and  in  cer- 
tain places  profoimd  nervous  disturbances,  which  can  be  ascribed  only 
to  acute  inflammatory  processes  uivolving  the  membranes  of  the  brain 
and  the  spinal  cord,  occur  in  the  course  of  the  disease  with  varying 
frequency,  at  times  in  large  numbers  of  cases.  At  the  onset  and  during 
the  course  of  these  cases,  the  stupor,  in  contrast  with  the  remaining  symp- 
toms, is  slight,  if  present  at  all.  Under  such  circumstances  the  patients 
complain — as  is  unusual  at  the  height  of  the  attack — of  most  severe,  per- 
sistent headache,  vertigo,  roaring  in  the  ears,  and  photophobia.  At  the 
same  time  or  soon  after  sacral  pain  and  pain  at  the  back  of  the  neck 
set  m,  with  painful  rigidity  of  the  vertebral  column,  especially  the  cer- 
vical portion,  and  characteristic  opisthotonos.  Even  touching  or  move- 
ment or  concussion  of  the  dorsal  and  sacral  cervical  region  induces  loud 
expressions  of  pain.  In  addition,  twitching  and  pains  in  the  extremities 
are  present,  and  great  tenderness  of  the  skin  and  muscles  on  pressure. 
The  patients  are  deprived  of  rest  and  sleep  by  day  and  night,  and 
complain  and  groan  constantly.     The  sensory  as  well  as  the  tendinous 


270  TYPHOID  FEVER. 

reflexes  are  generally  considerably  increased,  and  the  elicitatiou  of  the 
latter  is  especially  painful  to  the  patient.  In  some  cases  there  is 
polyuria,  with  difficulty  in  niictm-itiou.  Facial  herpes,  which  under 
other  circumstances  is  rare  in  the  course  of  typhoid  fever  occurs  with 
remarkable  frequency.  This  symptom-complex  may  occur  in  both 
severe  and  mild  cases.  The  intensity  of  the  attiick,  it  should  be 
expressly  pointed  out,  is  not  proportionate  to  the  severity  of  the 
meuingitic  symptoms.  A  mild  attack  of  typhoid  fever  may  be  attended 
with  severe  and,  conversely,  a  severe  attack  with  slight,  at  times 
transitory,  meningitic  manifestations. 

The  duration  of  meningitis  during  t}'phoid  is  exceedingly  variable. 
At  times  it  is  from  four  to  twelve  days ;  at  other  times  it  persists 
throughout  the  greater  portion  of  the  febrile  period.  Occasionally  it 
even  appciU's  to  prolong  the  latter  considerably.  I  have  observed  cases 
of  from  three  to  three  and  a  half  weeks'  duration.  Bernhard  ^  also 
refers  to  a  case  of  twenty  days'  duration.  I  have  never  observed 
renewed  appearance  of  the  meningitic  symptoms  during  a  relapse  of 
typhoid  fever. 

I  have  often  had  opportunity  for  anatomic  investigation  of  cases  of 
t}'phoid  fever  which  had  showed  symptoms  of  cerebrospinal  meningitis, 
both  those  in  which  the  symptoms  referable  to  the  central  nervous 
system  were  slight  as  compared  with  the  symptoms  to  which  death  was 
directly  attributable,  as  well  as  those  in  which  death  undoubtedly 
resulted  directly  from  cerebrospinal  meningitis.  The  first  group  is 
characterized  by  the  slight,  almost  negative,  anatomic  evidence.  One 
may  find  at  most  more  or  less  marked  hyperemia  of  the  soft  membranes 
of  the  brain  and  the  spinal  cord,  with  or  without  turbidity.  A  marked 
advance  m  the  interpretation  of  such  cases  is  furnished  by  the  interest- 
ing observation  of  Fr.  Schultze^  that,  although  under  such  circum- 
stances no  coarse  anatomic  lesions  appear  to  be  present,  nevertheless 
small-cell  infiltration  is  demonstrable  in  the  membranes  of  the  brain 
and  spinal  cord  in  the  course  of  the  vessels,  and  also  microscopic  foci 
of  similar  character  in  the  tissue  of  the  central  nervous  system.  In  5 
cases  presenting  unusually  well-marked  cerebrospinal  symptoms,  which 
were  doubtless  the  direct  cause  of  death,  I  was  able  at  autopsy  to 
demonstrate  the  familiar  anatomic  picture  of  purulent  cerebrospinal 
meningitis.  In  3  of  these  cases  especially  the  pia-arachnoid,  particu- 
larly on  the  convexity  and  lateral  aspects  of  the  brain,  was  involved, 
and  iu  less  degree  that  of  the  spinal  cord ;  while  in  the  2  other  cases 
the  membranes  of  the  brain  and  the  spinal  cord  were  equally  involved. 

^Berlin,   klin.   Woch.,  1886,  No.  50.  ^  Loc.  cit. 


SYMPTOMS  AND  COMPLICATIONS.  271 

In  these  cases  the  condition  had  developed  between  the  second  and  the 
fifth  week  in  the  course  of  attacks  of  typhoid  fever  of  severe  onset, 
with  in  part  an  unusually  long  febrile  stage,  and  the  disease  had 
terminated  fatally  after  a  duration  of  from  six  to  ten  days.  What 
relation  these  cases  bear  to  those  previously  mentioned  in  which  there 
was  no  suppuration  must  remain  uncertain  until  further  thorough 
bacteriologic  investigations  have  been  made.  To  me  it  seems  probable 
that  in  part  at  least  they  differ  from  one  another  only  in  degree.  In 
any  event,  I  was  able  in  my  purulent  cases  to  exclude  with  certainty 
any  underlying  complications,  either  general  septicemia  or  purulent 
affections  in  the  immediate  vicinity  of  the  skull  (ear,  nose). 

My  cases,  which  were  observed  at  the  beginning  of  the  decade  1880-89, 
were  not  thoroughly  examined  bacteriologically.  No  doubt  various  micro- 
organisms, possibly  also  mixed  infection,  will,  in  the  course  of  time,  be 
found  to  be  the  cause  of  the  meningitis.  In  this  connection  attention  will 
have  to  be  directed  especially  to  Staphylococcus  and  Streptococcus  pyogenes, 
to  pneumococci,  and  particularly  also  to  the  specific  micro-organisms  of 
epidemic  cerebrospinal  meningitis.  I  would  direct  attention  particularly  to 
this  point,  because  in  Hamburg  on  two  occasions  I  observed  the  striking 
fact  that  severe  meningitic  disturbances  in  the  course  of  typhoid  fever  were 
especially  well  marked  and  frequent  at  a  time  when  idiopathic  cerebrospinal 
meningitis  raged  in  the  city.  Besides  those  cases  probably  due  to  the 
pyogenic  cocci  or  meningococci,  it  is  now  quite  well  established  that  a 
certain  number  of  cases  are  due  to  the  localization  of  the  typhoid  bacillus 
itself  in  the  meninges.  Within  the  past  few  years  a  number  of  such  cases 
have  been  reported,  and  have  lately  been  collected  by  Hofmann.^  Leaving 
out  of  consideration  the  doubtful  cases,  at  least  10  have  been  reported  in 
which  the  typhoid-bacillus  was  definitely  obtained  from  the  meningeal 
exudate  in  pure  cultures.  Ohlmacher  ^  has  reported  2  such  cases  in  which 
the  typhoid-bacillus  was  most  carefully  identified,  and  the  histologic  changes 
described.  A  positive  observation  has  also  been  made  by  Quincke,^  who 
saw  death  occur  in  a  workman  on  the  fourteenth  day  of  an  attack  of 
typhoid  fever,  amid  symptoms  of  severe  cerebrospinal  meningitis,  and  was 
able  to  demonstrate  the  bacillus  of  Eberth  in  the  meningitic  exudate  as  the 
sole  pyogenic  agent.  In  most  of  the  cases  reported  as  due  to  Bacillus 
typhosus,  the  condition  has  been  one  of  a  purulent  leptomeningitis.  In  the 
case  reported  by  Hofmann,  however,  there  was  simply  an  increase  in  the 
amount  of  cerebrospinal  fluid  with  a  round-cell  infiltration  about  the  vessels 
of  the  pia  and  arachnoid.  The  meningeal  symptoms,  however,  were  most 
marked,  with  clonic  convulsions  during  the  six  hours  preceding  death.  This 
case  brings  forth  the  interesting  question  as  to  how  often  the  less-marked 
meningeal  symptoms,  frequently  seen  in  typhoid,  are  due  to  the  presence  of 
the  typhoid-bacilli  in  the  brain,  cord,  or  cerebrospinal  fluid.  An  interesting 
case  in  this  connection  is  one  which  occurred  lately  at  the  Johns  Hopkins 
Hospital,  in  which,  following  quite  marked  meningeal  symptoms,  including 
stiffness  of  the  neck  and  delirium,  a  lumbar  puncture  was  performed,  and 
from  the  cerebrospinal  fluid,  which  was  macroscopically  quite  clear  and  con- 

'  Deutsch.  med.   Woch.,  July  12,  1900.         ^  phUa.  Med.  Jour.,  August  28,  1897. 
*  Stiihlen,  "  Ueber  typhose  meningitis, "  Uer^in.  klin.  Woch.,  1894,  15. 


272  TYPHOID  FEVER. 

taiued  only  a  very  few  pus-cells,  the  typhoid-bacillus  was  obtained  in  pure 
culture.  After  several  days  the  meningeal  symptoms  entirely  cleared  up. 
That  in  the  future  resort  will  more  frequently  be  had  to  spinal  puncture, 
which  is:  also  not  rai'ely  indicated  for  therapeutic  purjwses,  for  the  etiologic 
ex[)lauatiou  of  the  meningitic  syni})toms,  need  only  be  indicated  at  this  place. 
It  is  an  interesting  fact  that  meningitic  symptoms  occasionally  occur  with 
great  frequency  in  certain  epidemics  and  in  certain  places,  and  that  they 
may  then  occur  in  groups  of  individuals  in  the  same  house  or  the  same 
family.  Thus,  I  observed  recently  in  the  Jakobsspital  5  nurses  stricken 
in  quick  succession  with  typhoid  fever,  probably  in  consequence  of  infection 
through  milk,  and  in  all  the  cases  meningitic  symptoms  predominated  from 
the  first  week  to  such  a  degree  that  in  the  first  case  the  diagnosis  was  as  a 
result  not  a  little  obscured. 

The  fact  that  cerebrospinal  symptoms  occur  in  a  considerable  number 
of  cases  in  the  late  febrile  period,  in  the  stage  of  irregular  temperature, 
and  the  first  part  of  convalescence,  M'as  long  ago  noted  by  Ducbeck, 
Griessinger,  Bnbl,  Leyden,  Erb,  and  myself.  Undoubtedly,  these  cases 
of  meningitis  arising  in  the  later  period  of  the  disease  are  among  the 
more  severe,  and  they  attracted  attention  therefore  relatively  early. 
The  fact,  however,  that  marked  meningitic  symptoms  may  appear  in 
the  earliest  period  of  typhoid  fever,  and  may  so  thoroughly  dominate 
the  clinical  picture  that  the  greatest  difficulty  in  diagnosis  may  arise, 
was  practically  unknown  before  I  called  attention  to  it.^ 

I  have  exceptionally  observ^ed  cases  in  which  remarkably  severe 
headache  with  rigidity  of  the  neck  and  hyperesthesia  existed  even  during 
the  period  of  incubation  of  typhoid  fever.  More  frequently  I  have 
observed  the  symptoms  in  question  appear  on  the  first  or  second  day 
after  the  commencement  of  the  fever,  at  times  naturally  suggesting 
genuine  cerebrospinal  meningitis,  and  the  real  nature  of  the  condition 
being  recognized  only  when  enlargement  of  the  spleen,  diarrhea,  and 
roseolse  appeared  at  the  end  of  the  first  or  the  beginning  of  the  second 
week  of  the  disease.  Undoubtedly,  if  one  wishes  to  classify  such  cases, 
they  might  be  designated  meningotyphoid. 

I  have  also  observed  meningitic  symptoms  appear  on  all  the  subse- 
quent days  of  the  first  week  as  well  as  in  the  second  week.  At  times 
their  onset  was  marked  by  a  chill  or  by  repeated  chills,  and  the  sur- 
prismg  development  of  facial  herpes.  I  have  observed  these  cases  of 
early  occurrence  far  more  frequently  than  those  that  set  in  during  the 

»  Sitzungsbericht  d.  Comj.  f.  %nn.  Med.,  Bd.  v.,  S.  469;  and  F.  "Wolff  (Keport 
from  my  department  in  the  Hamburg  General  Hospital),  Deutsch.  Arch.  f.  hlin.  Med., 
Bd.  xliii.  Fritz  alone  [Etudes  cliniques  siir  diver-Hea  sympt  spinaux  observ.  dans  la 
fievre  typhoide,  Paris,  De  la  Haye,  1864")  had  referred  to  this  condition  before  I  did. 
This  latter  publication  is  but  little  known  ;  my  own  attention  was  directed  to  it  by 
Bernhard  only  after  the  appearance  of  my  own  paper. 


SYMPTOMS  AND  COMPLICATIONS.  273 

third  week  or  later.     They  appear  to   be  more  varied  witli  regard  to 
severity  and  course,  but,  on  the  whole,  milder  tluui  the  latter. 

Symptoms  of  meningitis  during  the  course  of  an  attack  of  ty])hoid 
fever  are  seen  almost  exclusively  in  young  individuals,  in  males  less 
commonly  than  in  women  and  children.     I  liave  observed  this  condi- 
tion only  twice  in  patients  over  thirty-five  years  old.     Among  38  cases 
of  which  I  have  notes,  23  were  in  women,  10  in  men,  and  5  in  children. 
If,  as  has  already  been  mentioned,  in  cases  of  typhoid  fever  with  pro- 
found stupor,  symptoms  of  meningitis  develop,  especial  attention  should 
be  directed  to  the  possibility  of  the  symptom  being  due  to  a  primary 
purulent  process.     Thus  it  is  not  rare  for  existing  old  inflammation  of 
the  middle  ear  to  undergo  exacerbation  during,  and  perhaps  in  conse- 
quence of,  an  attack  of  typhoid  fever,  with  subsequent  extension  of  the 
process  to  the  meninges.     I  have  personally  observed  this  in  a  number 
of  instances,  and  in  2  cases  was  compelled  to  recommend  immediate 
trephining  of  the  mastoid  process.     Menmgitic  symptoms  have  been 
observed  also  in  the  sequence  of  recent  suppurative  inflammation  of  the 
middle  ear,  which  was  dependent  upon  typhoid  fever  (Louis,  Peacock '). 
Cerebrospinal  meningitis  is  quite  rare  as  one  of  the  manifestations 
of  septicemia  complicating  typhoid  fever.     I  have  observed  2  cases  in 
which  such  a  condition  developed  during  convalescence  in  consequence 
of  pyemia,  following  extensive,  deep  bed-sores.     In  one  of  these  cases 
purulent  sinus-thrombosis  developed,  and  in  the  other  an  abscess  of  the 
brain  as  large  as  a  pigeon's  egg,  and  two  smaller  purulent  foci  in  the 
external  layer  of  the  hemisphere,  were  present. 

I  have  observed  tuberculous  meningitis  exceptionally,  and  only 
during  convalescence,  then  occurring  either  as  the  cerebrospinal  form 
alone  or  as  one  of  the  manifestations  of  a  complicating  general  tubercu- 
losis. Attention  has  been  called  to  this  by  other  writers  also,  as,  for 
instance.  Trousseau.^ 

Meningeal  hemorrhage  not  of  inflammatory  origin  occurs,  on  the 
whole,  quite  rarely.  It  is  either  circumscribed  or  extends  over  a 
considerable  extent,  mamly  upon  the  surface  of  the  brain.  The 
circumscribed  hemorrhages,  when  they  give  rise  to  symptoms  at  all,  faU 
into  the  category  of  focal  lesions.  They  may  then  give  rise  to  hemi- 
plegia, especially  cortical  monoplegia  with  muscular  twitchings  upon 
one  side  or  in  circumscribed  areas ;  at  times  there  is  aphasia.  Less 
commonly  the  latter  occurs  alone.  Extensive  meningeal  hemorrhao-e 
has  been  observed  but  exceptionally.  I  have  personally  seen  2  cases 
in  markedly  alcoholic  men  of  middle  age  who  presented  a  hemorrhagic 

^  Med.  Times  and  Gaz.,  1856.  2  j^^^.^  ^^ 

18 


274  TYPHOID  FEVER. 

course  of  the  disease  in  general.  Death  occurrctl  in  one  at  the  end  of 
the  second,  and  the  other  in  the  middle  of  the  third,  week.  In  both  the 
symptoms  set  in  in  an  apoplectiform  manner,  and  they  persisted  for  two 
and  three  days,  respectively,  until  death. 

Alterations  in  the  Cerebral  Tissue  and  its  Vessels. — It 
has  been  mentiorieil  in  the  anatomic  section  that  sym])toms  dependent 
upon  coarse  lesions  of  the  cerebral  tissue  and  its  vessels  are  not  frequent. 
When  they  are  present,  they  occur  principally  during  the  later  stages  of 
the  disease,  in  the  last  part  of  the  febrile  period,  during  convalescence, 
or  even  later,  so  that  they  may  with  especial  propriety  be  designated 
sequels.  AVe  have  observed  hemorrhages,  embolism,  and  thrombosis  of 
the  large,  moderate-sized,  and  small  cerebral  vessels,  a\  ith  circumscribed 
and  profuse  softening,  and  rarely  abscesses,  as  anatomic  features. 
Among  the  clinical  phenomena  to  which  they  give  rise,  and  which 
often  during  life  are  difficult  of  correct  interpretation  with  regard  to  the 
anatomic  basis,  hemiplegia,  with  facial  and  hypoglossal  paralysis,  and 
right-sided  palsy,  occasionally  with  aphasia,  may  be  pointed  out. 

1  have  personally  observed  2  eases  of  this  character.  lu  the  one,  which 
terminated  tatally  in  the  course  of  eighteen  hours,  the  condition  was  depen- 
dent upon  recent  hemorrhage  into  the  left  lenticular  nucleus  and  its  vicinity  ; 
while  in  the  second  case,  which  likewise  terminated  fatally  in  the  course  of 
a  few  days,  embolism  of  the  left  Sylvian  artery  was  present.  A  case  proba- 
bly susceptible  of  a  similar  explanation  has  been  reported  by  Clarus.^  Two 
other  cases  of  right-sided  hemiplegia  with  aphasia  and  choreiform  twitching, 
particularly  in  the  arms,  which  were  under  my  observation,  terminated  in 
complete  recovery.  I  am  uncertain  whether  hemorrhage  into  the  cerebral 
tissues  or  into  the  meninges  was  the  underlying  condition  in  these  cases. 
Other  writers  also,  especially  Griessinger,'  Jackson,'^  Benedikt,*  Berger,^ 
Nothnagel,''  and  Striimpell,'  report  cases  of  cerebral  hemorrhage  in  the 
course  of  typhoid  fever. 

Osier  **  has  reported  the  case  of  a  young  man  who,  during  a  mild  attack 
of  typhoid  fever,  on  the  ninth  day  of  his  illness  suddenly  developed  general 
bilateral  clonic  convulsions,  which,  though  general,  were  more  intense  on 
the  right  side.  The  convulsions  continued  at  intervals  up  to  his  death,  ten 
hours  later.  At  autopsy  there  was  found  thrombosis  of  the  ascending  parietal 
and  parietotemporal  branches  of  the  middle  cerebral  artery.  In  a  second 
case,  that  of  a  man  aged  forty-six,  in  the  third  week  of  a  moderately  severe 
attack  of  typhoid  fever,  there  was  a  gradual  onset  of  paralysis  of  the  left 
side.  Death  occurred  four  days  later,  and  at  autopsy  an  area  of  thrombotic 
softening  in  the  internal  capsule  was  found.  In  two  other  cases  of  hemi- 
plegia with  sudden  onset,  one  of  them  with  convulsions,  there  was  recovery 

'  Inmig.  Diss.,  Wiirzburg,  1874,  and  Jahrb.  f.  Kinderh.,  Bd.  vii. 

2  Loc.  cit.  3  Edi7ib.  Med.  Jour.,  1867. 

*  Wien.  med.  Prcsse,  1868.  *  Berlin,  klin.   Woch.,  1870. 

^  Deutsch.  Arch.f.  klin.  Med.,  1872.     The  paper  of  Nothnagel  contains  a  com- 
plete collection  of  the  literature  up  to  1872  on  the  nervous  sequels  of  typhoid  fever. 
'  Lehrbuch.  8  Johns  Hopkins  Hosp.  Rep.,  vol.  viii. 


SYMPTOMS  AND  COMPLICATIONS.  275 

from  the  fever  with  only  partial  recovery  from  the  hemiplegia.  Welch ' 
mentions  4  other  fatal  cases  of  thrombosis  of  the  middle  cerebral  arteries. 
Hawkins^  has  made  a  most  careful  study  of  hemiplegia  in  typhoid  and  has 
collected  17  cases  from  the  literature.  Two  of  the  cases  died,  and  in  both 
of  these  there  was  a  thrombosis  of  the  middle  cerebral  artery. 

I  have  observed  abscess  of  the  brain  ])iit  twice  in  the  course  of 
typhoid  fever.  The  cases  were  those  previously  referred  to  (p.  121), 
which  were  dependent  upon  septicemia  and  were  attended  with  purulent 
meningitis  of  the  convexity ;  the  clinical  symptoms  and  course  being 
those  of  the  latter  condition. 

In  addition  to  aphasia  dependent  upon  profound  disease  of  the 
brain,  disturbances  of  speech  of  cortical  origin  in  the  course  of  typhoid 
fever  are  deserving  of  special  mention,  since  they  form  a  special  group 
and  are  characterized  by  the  fact  that  they  occur  alone  or  at  least  with 
only  circumscribed  paralysis,  and  generally  terminate  in  recovery  with 
comparative  rapidity.  If  they  are  attended  at  all  with  motor  distur- 
bances in  the  trunk  or  the  extremities,  these  are  generally  of  the  char- 
acter of  tremor  or  ataxia.  On  account  of  the  rapid,  favorable  course, 
these  cases  can  hardly  be  attributed  to  other  causes  than  to  slight 
anatomic  alteration  not  permanently  injuring  the  speech-centers.  It  is 
peculiar,  further,  that  these  cases  occur  almost  solely  during  conva- 
lescence, and  especially  in  children  and  young  persons. 

I  have  personally  observed  the  following  cases  of  this  character  :  The 
first  occurred  in  an  irritable,  spoiled  girl  ten  years  old,  with  a  neurotic  predis- 
position, who,  during  convalescence  from  a  severe  and  protracted  attack  of 
typhoid  fever,  was  suddenly  seized  on  the  fourth  afebrile  day  with  almost 
complete  loss  of  speech  after  slight  disturbances  had  been  noticed  on  the 
previous  day.  The  condition  was  one  of  ataxic  aphasia.  Consciousness 
and  the  remaining  functions  of  the  body  were  preserved  ;  I  would  note  espe- 
cially that  no  paralysis  of  the  extremities  developed.  After  this  condition 
had  persisted  unchanged  for  two  weeks  the  disorder  of  speech  began  to 
improve,  and  after  the  lapse  of  five  weeks  complete  recovery  had  ensued. 

The  second  case  occurred  in  a  merchant's  apprentice,  fifteen  years  old, 
whose  mother  had  died  in  a  hospital  for  the  insane,  and  who  prior  to  the 
onset  of  a  severe  attack  of  typhoid  fever  had  engaged  in  excessiVe  physical 
activity  ;  he  likewise  was  suddenly  seized  at  the  end  of  the  third  week  of 
the  disease,  in  the  stage  of  steep  curves,  in  the  daytime,  with  ataxic  aphasia 
which  was  accompanied  by  considerable  transitory  elevation  of  temperature. 
Consciousness  remained  wholly  undisturbed  from  the  beginning  of  the  dis- 
order. Improvement  began  within  a  week,  and  in  the  course  of  three  and 
a  half  weeks  almost  complete  recovery  had  taken  place,  except  for  slight 
difficulty  in  forming  words  and  syllables,  which  difficulty  persisted  for 
months.  While  still  in  bed,  and  after  getting  up,  ataxic  disturbances  were 
demonstrable  in  the  lower  extremities ;    sensation,   however,   being  undis- 

^  Abbutt's  System  of  Medicine,  1899,  vol.  vii.,  London. 
^  Clin.  Soc.  Trans.,  vol.  sxvi.  * 


276  TYPHOID  FEVER. 

turbe.d  aud  the  patellar  teiulon-retlexeri  normal.     These  ataxic  disturbauces 
had  also  completely  disappeared  in  the  course  of  about  ten  weeks. 

References  in  the  literature  to  this  peculiar  variety  of  aphasia  date  back 
to  a  comparatively  early  period.  After  Klusemann,"  Baudelocque,-  Weise/ 
aud  Trousseau*  had  called  attention  to  it,  Clams''  ami  Kiihn ''  engaged  in  a 
more  thorough  study  of  the  subject.  Among  28  cases  collected  by  Kiihn, 
25  were  iu  children,  and  the  remaining  8  were  also  in  young  persons. 
Except  for  the  preseuce  of  ataxia  iu  2  cases,  Kiihn  does  not  refer  to  any 
other  associated  nervous  disturbances  iu  his  cases.  Death  occurred  in  but 
1,  while  complete  recovery  eusued  in  the  remainder  in  from  three  to  six 
weeks,  rarely  later. 

Other  forms  of  cerebral  monoplegia  involving  the  armp,  the  legs,  or 
only  certain  groups  of  muscles,  have  likewise  been  recorded  exception- 
ally in  the  literature/  They  have,  however,  not  been  carefully  investi- 
gated, and  the  condition,  especially  in  the  older  cases,  cannot  be  distin- 
guished from  certain  varieties  of  peripheral  neuritis. 

Hemorrhage  aud  inflammatory  softening  of  the  medulla  oblongata 
deserve  special  mention. 

The  case  of  this  kind  reported  by  Kiimmell  ®  is  interesting,  as  it  pursued 
the  course  of  an  acute  ascending  paralysis,  as  did  also  the  case  of  softening 
of  the  bulb  with  capillary  hemorrhages  which  was  uuder  my  observation 
(see  Anatomy,  p.  121).  The  latter  occurred  in  a  man,  thirty  years  old, 
who  was  brought  to  the  hospital  from  the  harbor,  profoundly  ill,  in  a  coma- 
tose state,  without  any  history.  There  were  high  fever,  moderate  meteor- 
ism,  palpable  enlargement  of  the  spleen,  rigidity  of  the  neck,  aud  stiffness 
of  the  entire  vertebral  column,  hyperesthesia  of  the  whole  body,  extensive 
labial  herpes,  but  no  roseolse.  Death  occurred  on  the  second  day  of  resi- 
dence iu  the  hospital.  The  autopsy  disclosed  the  lesions  of  an  attack  of 
typhoid  fever  at  the  end  of  the  third  week,  and,  in  addition  to  the  bulbar 
lesions  mentioned,  marked  hyperemia  of  the  pia-arachnoid  of  the  brain  and 
the  spinal  cord,  with  slight  turbidity  of  the  cerebrospinal  fluid. 

The  cases  reported  by  Eisenlohr''  may  also  best  be  cited  here.  He 
described  3  cases  of  conspicuous  involvement  of  the  bulbar  nerves  in  the 
course  of  typhoid  fever,  which  were  characterized  especially  by  dysarthria, 
paralysis  in  the  distribution  of  the  facial  nerve,  and  in  part  of  the  motor 
distribution  of  the  trigeminal  nerve  (weakness  or  spasm  in  the  niasseter 
muscles).  All  3  patients  exhibited  evidences  of  profound  infection  and  were 
attacked  with  the  nervous  symptoms  during  the  febrile  stage.  In  2  cases 
recovery  ensued  with  comparative  rapidity,  while  death  occurred  in  the 
third,  and  the  autopsy  disclosed  as  the  cause  for  the  troulfle  invasion  of  the 
medulla  oblongata  by  organisms  resembling  Staphylococcus  citreus  and  by 
peculiar  bacilli.     As  in  my  case  of  invasion  of  the  spinal  cord  by  typhoid- 

^  Preuss.  med.  Vereinszeitung,  1854,  No.  12. 

*  Compt.  rend,  de  la  Soc.  de  Biol.,  1860.  ^  Jour.  f.  Klnderh.^  18G4. 

♦  Gaz.  desHop.,  1864.  *  Loc.  cit. 

^  Deutsch.  Arch.f.  klin.  Med.,  Bd.  xxxiv.  This  contains  also  detailed  reference 
to  the  literature. 

■^  See  Nothnagel,  loc.  cit.  «  Zeit.  f.  klin.  Med.,  Bd.  ii.,  Heft  2. 

9  Deutsch.  med.  Woch.,  1893,  No.  6. 


SYMPTOMS' AND  COMPLICATIONS.  277 

bacilli,  so  also  in  Eisenlohr's  fatal  case,  scarcely  any  actual  destruction  of 
tissue  in  the  medulla  oblongata  was  demonstrable. 

A  case  under  my  observation  in  the  year  1884,  to  which  my  attention 
was  again  called  only  after  the  appearance  of  Eisenlohr's  report,  may  be 
included  in  this  group.  It  occurred  in  a  servant-girl,  nineteen  years  old, 
suffering  from  an  attack  of  typhoid  fever  of  moderate  severity.  At  the  ei)d 
of  the  third  week  disturbances  of  speech  similar  to  those  described  by 
Eisenlohr  suddenly  appeared.  The  sensorium  was  clear,  there  was  no  other 
paralysis;  and  the  muscles  of  mastication  were,  according  to  my  notes,  intact. 
Complete  recovery  gradually  ensued  in  the  course  of  four  and  a  half  weeks. 

Certain  cerebral  nerves  appear  to  be  involved  but  rarely  in  the 
course  of  typhoid  fever.  Facial  or  hypoglossal  paresis  is  mentioned 
exceptionally.  Possibly  the  few  reported  cases  of  paralysis  of  accom- 
modation during  convalescence  (Gubler/  Kittel  ^)  belong  in  this  group.* 
The  occurrence  of  paralysis  of  the  vocal  cords  is,  in  part  at  least,  to  be 
included  here ;  while  another  portion  of  the  cases  are  attributable 
directly  to  local  disease  of  the  larynx,  such  as  inflammatory  swelling 
of  the  mucous  membrane  and  the  submucous  tissues,  and  ulceration 
(see  p.  239  and  the  succeeding  pages).  The  condition  present  in  the 
first  class  is  undoubtedly  one  of  innervational  disturbance  in  the  dis- 
tribution of  the  recurrent  laryngeal  nerve.  Bilateral  or  unilateral 
paralysis  of  all  the  muscles  supplied  by  this  nerve  has  but  rarely 
been  observed ;  more  frequently,  paralysis  of  certain  groups  of  muscles, 
especially  of  the  abductors  of  the  vocal  cords,  and  somewhat  less  com- 
monly that  of  the  adductors. 

The  earliest  reported  case  is  probably  the  well-known  one  of  Traube,*  in 
which  paralysis  of  the  vocal  cords,  together  with  other  severe  nervous 
manifestations,  developed  during  the  first  week  of  the  disease.  Tiirk  and 
Nothnagel  (who  gives  the  earlier  literature)  have  reported  similar  cases. 
An  extensive  study  has  recently  been  published  by  Boulay  and  H.  Mendel.* 
Lublinsky"  also  deserves  credit  for  his  investigation  of  this  subject.  Other 
cases,  ^  especially  of  paralysis  of  the  crico-arytenoideus  posticus,  have  been 
reported  by  Liining,^  Rehn,''  Jourasse,'"  and  Pel." 

Sensory  disturbances  in  the  distribution  of  the  cranial  nerves  appear 
to  be  even  more  infrequent  than  motor  disturbances.     Trifacial  neu- 

1  Arch.  gen.  de  Med.,  1860.  ^  wien.  med.  Zeit.,  1865. 

^  See  further  at  a  later  page  the  dissenting  opinion  of  Fdrster  and  Knies  (p.  285). 

*  Qesammelte  Beitrdge,  Bd.  ii.  ^  Arch.  gen.  de  Med.,  Dec,  1894. 

'^  Deutsch.  med.   Woch.,  1895,  No.  26. 

''  The  monograph  of  Przedborski  (Yolkmann's  Sammlung  klin.  Vortr.,  May, 
1897,  No.  182),  which  appeared  while  this  volume  was  in  press,  attempts  to  show  that 
paralysis  of  the  vocal  cords  in  the  course  of  typhoid  fever  is  a  quite  frequent  occur- 
rence. Further  observations  will  be  required  to  determine  to  what  extent  this  striking 
statement,  which  is  contrary  to  the  opinions  hitherto  held,  is  correct. 

^  Langenbeck' s  Archiv,  Bd.  xxx.  *  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  xviii. 

1"  Deuisch.  med.  Woch.,  1879,  Nos.  14  and  15.  "  Yirchow-Hirsch,  1879. 


278  TYPHOID  FEVER. 

ralgia,  persisting  into  convalescence,  is  referred  to  by  various  observers, 
among  others  by  Striimpell.  I  have  personally  observed  no  case  of 
this  character. 

AflFections  of  the  Spinal  Cord. — These  also  are  doubtless 
quite  rare,  much  rarer  than  Avas  believed  at  a  time  when  peripheral 
neuritis  and  its  clinical  manifestations  were  little  known,  and  jiarajilcgia, 
particularly  of  the  lower  extremities,  was,  without  further  consideration, 
cla^ised  among  the  spmal  diseases.  For  this  reason  the  earlier  literature  ^ 
cannot  be  accepted  without  qualification.  Cases  of  myelitis  definitely 
confirmed  by  anatomic  observations  have,  however,  been  obsers^ed  in  a 
number  of  instances.     Such  a  case  was  recently  observed  in  my  clinic. 

I  may  at  this  point  refer  also  to  the  case  described  by  me  in  1886  (see 
also  p.  121),  in  which  a  strong  man,  thirty-one  years  old,  died  in  the  first 
half  of  the  second  week  of  an  attack  of  typhoid  fever,  with  most  marked 
symptoms  of  acute  ascending  (Landry's)  spinal  paralysis  (or,  if  that  term 
be  preferred,  myelitic  aciitissinia).  Microscopic  and  careful  bacteriologic 
examination  of  the  spinal  cord  disclosed  beyond  doubt  invasion  by  typhoid- 
bacilli,  which  could  be  demonstrated  both  in  transverse  sections  autl  in 
cultures. 

A  case  almost  identical  with  my  own  had  been  described  by  Leudet '  in 
1861.  His  patient  was  seized,  in  the  third  week  of  a  mild  attack  of  typhoid 
fever,  after  she  had  actually  entered  upon  convalescence,  with  acute  spinal 
paralysis,  ascending  from  the  iower  extremities,  which  terminated  faflally  in 
the  course  of  seven  days,  with  symptoms  of  asphyxia,  and  in  which  con- 
sciousness was  preserved  throughout. 

A  somewhat  similar  case,  proving  fatal  at  the  end  of  eighteen  hours,  has 
been  reported  by  Schiff^  The  examination  of  the  cord  in  this  case  showed 
an  acute  hemorrhagic  transverse  myelitis  at  the  level  of  the  fourth  and  fifth 
cer^ncal  segments.     Cultures  in  this  case  were  negative. 

I  know  of  no  other  similar  case.  They  thus  appear  "to  be  quite  rare. 
Whether  in  future  cases  bacilli  will  be  demonstrable,  as  they  were  in  my 
case,  in  the  tissue  of  the  central  nervous  system,  cannot  be  stated  in 
advance,  and  their  presence  is  possibly  only  of  subordinate  significance. 
It  is  readily  conceivable  that  toxic  effects  of  especial  severity  may  give  rise 
to  similar  symptoms.  It  is  noteworthy,  further,  that  quite  similar  severe 
conditions  of  acute  ascending  paralysis  have  been  described  in  the  course 
of  other  infectious  diseases  also  ;  for  instance,  in  cases  of  variola  l)y  Gubler, 
Bernhardt,  and  others,  by  Landry  in  cases  of  diphtheria  and  cholera,  and 
by  the  latter  and  Leyden  in  cases  of  pneumonia. 

Still  other  clinical  pictures  undoubtedly  of  spinal  origin  have  been 
observed.  Thus  Westphal,^  upon  the  basis  of  a  case  terminating  in 
recovery,  has  called  attention  to  a  peculiar  variety  of  marked  ataxia 
following  typhoid  fever,  associated  with  tremor  in  the  lower  extremities, 
without  actual  impairment   of  gross   strength   or   of   sensibility.     The 

^  See  the  monograph  of  Nothnagel.  ^  Gaz.  med.  de  Paris,  1861,  No.  19. 

s  Dejitsch.  Arch.f.  klin.  Med.,  1900,  Bd.  Ixvii. 
*  Arch.  f.  Psych,  u.  New.,  Bd.  iii.,  Heft  2. 


SYMPTOMS  AND  COMPLICATIONS.  279 

condition  was  associated  with  disorders  of  speecli  of  the  bulbar  type 
resembling  those  attending  multiple  sclerosis.  A  similar  condition  has 
apparently  been  observed  by  Eichhorst  and  Striimpell.' 

Multiple  insular  sclerosis  has  also  been  observed  clinically,  and  in  a 
number  of  instances  anatomically,  in  cases  of  typhoid  fever.  In  com- 
parison with  its  occurrence  in  other  acute  infectious  diseases,  this  con- 
dition appears  to  be  not  extremely  rare  in  typhoid. 

Pierre  Marie''  observed,  among  25  cases  of  insular  sclerosis  dependent 
upon  infectious  diseases,  11  in  which  this  condition  was  a  sequel  of  typhoid 
fever.  The  military-sanitary  report  of  the  French  campaign  of  1870-71 
likewise  refers  to  similar  cases.  Ebstein '  was  one  of  the  first  to  call  atten- 
tion to  this  interesting  complication.  His  patient  exhibited  bulbar  distur- 
bances of  speech  and  ataxia,  without  any  other  impairment  of  motor  power 
or  sensation.  Anatomic  examination  disclosed  insular  gray  degeneration  of 
the  spinal  cord  and  the  bulb. 

Cases  of  spinal  paralysis  of  childhood  have  been  mentioned  by  a 
number  of  writers  as  of  rare  occurrence  in  the  course  of  or  toward  the 
close  of  the  attack  of  typhoid  fever.  The  earlier  reports  are  not  based 
upon  anatomic  examination.*  Recently  Richardier ''  has  published  a 
report  of  2  cases  of  this  kind,  which,  however,  I  have  not  yet  been  able 
to  obtain  in  the  original. 

In  concluding  this  section,  a  few  words  may  be  stated  with  regard  to 
the  state  of  the  reflexes  in  cases  of  typhoid  fever.  In  Germany  only 
Striimpell  has  hitherto  discussed  them,  while  French  investigators 
appear  to  have  made  extensive  observations.  I  have  personally  made 
some  observations  at  various  times  and  in  an  irregular  manner,  but 
which,  nevertheless,  have  yielded  certain  data.  Like  Striimpell,  I  have 
found  in  severe  cases  in  patients  who  were  greatly  reduced,  toward  the 
end  of  the  fever  or  during  convalescence,  marked  exaggeration  of  the 
patellar  tendon-reflexes.  Often  I  was  even  able  to  elicit  slight  or  even 
a  marked  Achilles  tendon-reflex.  In  mild  and  moderately  severe  cases 
the  patellar  tendon-reflex  is  exceedingly  variable  at  the  height  of  the 
disease.  Rarely  it  is  entirely  wanting,  but  in  the  great  majority  of 
cases  it  remains  normal  or  is  somewhat  enfeebled.  Toward  the  end  of 
the  attack  and  during  the  period  of  convalescence,  even  in  mild  cases, 
I  have  observed  now  and  again  moderate  exaggeration  of  the  reflexes. 

^  Mentioned  in  their  test-books. 

2  Vo7-lesungen  uber  Krankheiten  des  Ruckeiimarks^  German  translation  by  "Weiss, 
Vienna,  1894. 

^  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  ix.  and  x. 

*  See,  for  instance,  Benedikt,  Lehrbuch  der  Nervenkrankheiien. 

*  These.,  Paris,  1885,  cited  by  Marie,  who  appears  himself  to  have  made  no  similar 
observation. 


280  TYPHOID  FEVER. 

In  children  I  have  observed  enfeeblement  and  absence  of  the  reflexes 
with  relatively  greater  frequency  than  in  adults. 

General  Neuroses. — Chorea  minor,  to  which  Killiet  and  Barthez 
have  called  attention,  is  rarely  mentioned  as  a  sequel  of  tyj^hoid  fever. 

I  have  persoually  observed  a  woman,  thirty-une  years  old,  who  acquired 
severe,  chronic  chorea  minor  in  her  tweuty-tifth  year,  dm-ing  convalescence 
from  typhoid  fever.  The  history  relating  to  this  point  was  hased  upon  the 
statement  of  a  most  trnstworthy  physician,  who  treated  the  woman  during 
her  attack  of  typhoid  fever.  I  have  also  observed  choreic  conditions  in  3 
children  in  the  course  of  typhoid  fever.  In  one  case,  which  developed 
during  convalescence  from  an  attack  of  typhoid  fever  prolonged  over 
six  weeks,  the  condition  was  principally  one  of  unilateral  choreic  twitching, 
recovery  from  which  took  place  in  the  course  of  six  weeks.  The  second 
child,  in  whom  the  characteristic  twitching  ai)peared  during  the  third  week 
of  the  attack  of  fever,  recovered  two  and  a  half  months  after  convalescence. 
With  regard  to  the  third  case  I  have  no  further  notes. 

In  a  case  at  the  Johns  Hopkins  Hospital  of  a  young  woman  who  had 
had  chronic  chorea  for  a  year  before  the  onset  of  typhoid  fever,  there  was  a 
disappearance  of  the  choreic  movements  during  the  height  of  the  fever,  with 
a  gradual  return  during  convalescence. 

Of  other  neuroses,  reference  may  be  made  to  the  occurrence  of 
paralysis  agitans  (Benedikt).  I  have  personally  obser\'^ed  this  compli- 
cation but  once,  in  a  woman,  forty-six  years  old,  occurring  late  during 
convalescence,  and  then  persisting  without  change.  Exophthalmic 
goiter  has  been  mentioned  by  Waldenburg  as  a  sequel  of  tj^phoid  fever. 
Eichhorst  and  others  have  seen  diabetes  insipidus  occur  in  connec- 
tion -with  typhoid  fever.  I  have  personally  encountered  no  case  of 
either  complication.  In  1889,  Gibney  described  a  sequel  of  typhoid 
fever  which  he  called  "  the  typhoid  spine,"  and  which  he  regarded  as  a 
perispondylitis.  Osier  has  since  reported  a  number  of  quite  similar 
cases,  most  of  which  he  regards  as  examples  of  a  painful  neurosis, 
analogous  to  the  painful  condition  met  with  in  the  "  hysteric  spine " 
and  the  "  railway  spine."  It  usually  comes  on  during  convalescence  in 
neurotic  individuals,  and  the  slightest  bending  movements  of  the  back 
may  elicit  expressions  of  the  most  acute  pain. 

I/esions  of  the  Peripheral  Nerves. — The  peripheral  nerves, 
especially  those  of  spinal  origm,  appear  to  be  involved  more  frequently 
than  the  spinal  cord.  As  in  other  infectious  diseases,  the  condition  is 
usually  one  of  neuritis,  which  may  manifest  itself  as  an  atrophic  paral- 
ysis of  certain  muscles,  muscle-groups,  or  an  entire  extremity,  or  even 
as  a  paraplegia,  or,  in  still  wider  distribution,  with  the  clinical  picture 
of  pronounced  polyneuritis. 

Both  the  clinical  and  the  anatomic  knowledge  of  neuritis  itself,  and 
the  observation  of  its  occurrence  in  the  course  of  typhoid  fever,  are 


SYMPTOMS  AND  COMPLICATIONS.  281 

still  comparatively  recent.  It  is  possible,  however,  as  has  been  pre- 
viously intimated,  that  not  a  few  cases  of  paralysis  supposed  to  be  of 
spinal  origin  were  actually  due  to  neuritis.  In  this  category  belong 
tae  cases  of  atrophic  paralysis  in  which  the  muscles  exhibited  a  reaction 
of  degeneration  and  loss  of  electric  irritability,  with  tenderness  on 
pressure,  associated  with  subjective  and  objective  disturbances  of  sen- 
sation, and  in  which,  even  in  advanced  cases,  recovery  or  material 
improvement  took  place.  Leyden  early  referred  to  the  probability  of 
the  more  frequent  occurrence  of  peripheral  neuritis  in  cases  of  typhoid 
fever  in  his  book  on  Diseases  of  the  Spinal  Cord.  Neuritic  paralysis 
occurs  less  frequently  at  the  height  of  the  disease  than  toward  its  close, 
and  into  late  convalescence.  I  have  observed  neuritic  paralysis  of  both 
lower  extremities  develop  as  late  as  the  twenty-ninth  day  after  deferves- 
cence, after  the  patient  had  already  gotten  out  of  bed.  Such  late  occur- 
rence is,  it  is  true,  still  more  usual  after  diphtheria  than  after  tj^phoid  fever. 

Paralysis  due  to  neuritis,  both  when  extensive  and  more  particularly 
when  circumscribed,  appears  to  involve  the  lower  extremities  more  fre- 
quently than  the  trunk  and  the  upper  extremities  when  it  occurs  in  cases  of 
typhoid  fever.  Among  my  cases  are  2  of  paralysis  in  the  peroneal  region, 
and  1  each  of  paralysis  of  the  adductors  of  the  thigh  and  of  the  quadriceps. 
Paralysis  of  the  latter  has  been  mentioned  also  by  Krafft-Ebing,^  as  well  as 
by  Nothnagel  and  Surmay.^  Of  other  forms  of  neuritic  paralysis,  that  of 
the  long  muscles  of  the  back,  the  serratus  (Euleuburg),  as  well  as  that  of 
the  ulnar  and  the  median,  has  been  recorded  in  the  literature. 

Among  the  cases  of  paraplegia  of  the  lower  extremities,  4  cases  reported 
by  Nothuagel  deserve  mention.  Alexander^  has  also  reported  such  a  case 
in  an  adult.  I  have  personally  seen  neuritic  paralysis  of  both  lower  ex- 
tremities in  a  boy,  eight  years  old,  which  began  as  early  as  the  second  week 
of  a  mild  attack  of  typhoid  fever,  and  from  which  recovery  ensued  after  a 
duration  of  six  months.  Cadet  de  Gassicourt  *  and  Henoch  ^  had  previously 
called  attention  to  this  complication  during  childhood.  Finally  the  fact 
may  be  mentioned  that  neuritic  processes  may  develop  also  without  atrophic 
paralysis  ;  in  fact,  almost  wholly  without  clinical  manifestations,  as  Buhl 
and  Bernhardt®  and  recently  Pitres  and  Vaillard  have  demonstrated  ana- 
tomically. 

Sensory  disturbances  on  the  part  of  the  spinal  nerves  are  not  quite 
so  frequent  as  the  motor  paralyses.  Cutaneous  anesthesia  is  men- 
tioned by  Duchenne,^  Griessinger,^  Gubler,^  and  subsequently  by  numer- 
ous other  writers,  as,  for   instance,  Krafft-Ebing  ^"  and  Baumiler."     It 

^  Beobachtungen  und  Studien  uber  Abdominaltyphus^  1871. 
2  Arch.  gen.  de  Med.,  1865,  T.  1.  ^  Deidsch.  med.  Woch.,  1886. 

*  Traites  clir-.  des  mat.  de  Venfance,  1882,  T.  ii.  ^  Charite-Annalen,  1892. 

8  Loe.  cit.  '  De  I'electrisat.  locale,  1861.  ^  j^q,.   ^.^ 

^  Loc.  cit.  10  Loc.  cit. 

1'  "  Klinische  Beobachtungen  iiber  Abdominaltyphus, "  Deutseh.  Arch.  f.  klin. 
Med.,  Bd.  iii. 


282  TYPHOID  FEVER. 

has  occurred  also  in  several  instances  in  my  experience,  and  is  mani- 
fested in  part  by  impairment  or  complete  abolition  of  sensation  through- 
out the  distribution  of  certain  nerves  or  in  quite  circumscribed  areas  of 
the  skin.  So  far  as  I  can  recall,  the  various  forms  of  sensation  were 
equally  impaired.  Cases  of  cutaneous  anesthesia,  such  as  are  observed 
during  convalescence,  especially  in  adult  females,  involving  extensive 
areas,  without  being  conliuetl  to  detiuitc  nerve-areas,  appear  to  belong  to 
the  group  of  hysteric  disorders,  which  are  not  rarely  encountered  in 
the  sequence  of  typhoid  fever. 

More  frequent  than  the  simple  derangements  of  sensation,  and 
especially  more  vexatious,  are  the  neuralgias.  Among  these,  neuralgic 
pains  in  the  toes  and  the  heel,  and  also  in  the  remaining  portions  of  the 
sole  of  the  foot,  have  occurred  in  my  experience  with  particular  fre- 
quency. Comparatively  rare  at  the  height  of  the  disease,  they  are 
likely  to  appear  especially  during  the  stage  of  defervescence  and  the 
first  part  of  the  period  of  convalescence,  to  the  great  distress  of  the 
patient  and  also  of  the  physician,  to  whom  the  obstinacy  of  the  dis- 
order soon  becomes  apparent.  At  times  the  patient,  under  such  circum- 
stances, is  imable  to  rest  the  foot  upon  the  heel,  so  that  this  must  be 
placed  upon  a  concave  surface ;  while  at  other  times  the  bed-clothing 
must  be  supported  by  means  of  hoops,  in  order  that  it  may  not  exert 
pressure  upon  the  painful  toes.  Fortunately,  the  pains  eventually  dis- 
appear, generally  Avithout  special  intervention.  Nevertheless,  I  have 
exceptionally  observed  them  to  persist  for  a  considerable  period  of  time, 
in  one  mstance  for  a  year  and  a  half,  and  in  another  for  more  than  two 
years.     In  both  instances  neuralgia  of  the  heel  was  present. 

Neuralgia  of  the  sole  of  the  foot  and  of  the  toes  has  been  long  and 
generally  known.  Among  those  who  have  referred  to  it  are  Ducheck,^ 
Liebermeister  and  Hagenbach,^  Jiirgensen,''  JSTothnagel,*  Fritz,''  and 
KrafPt-Ebing.^  It  is  mentioned  also  in  the  Sanitary  Report  of  the 
German  Armies  for  1870—71.  Sciatica  appears  to  be  much  less 
common  (Benedikt,  Nothnagel).  I  have  never  encountered  it.  I  have 
observed  in  a  woman,  forty-one  years  old,  who  had  a  neurotic  tendency, 
an  extensive,  severe  neuralgia  in  the  distribution  of  the  brachial  plexus, 
in  association  with  persistent  fibrillary  muscular  contractions  in  the  del- 
toid and  the  triceps,  but  without  atrophic  paralysis.  Recovery  ensued 
in  the  course  of  three  months. 

I  have  observed  intercostal  neuralgia  in  2  cases,  in  1  associated  with 
herpes  zoster ;  occipital  neuralgia  in  3  cases,  the  first  developing  during 

'  Loc.  cit.  ^  Loc.  cif.  ^  Loc.  cit.  *  Loc.  cit.  ^  Loc.  cit. 

^  Klinische  Studien  iiber  de  Behandlung  des  Abdominaltyphus. 


SYMPTOMS  AND   COMPLICATIONS.  283 

the  period  of  irregular  temperature,  and  tlie  other  two  during  conva- 
lescence. Recovery  ensued  in  all  3  cases,  in  1,  it  is  true,  only  after  the 
lapse  of  five  months,  but  in  the  other  2  in  the  course  of  a  few  weeks. 
Neuralgia  in  the  distribution  of  the  lumbar  and  the  crural  nerves, 
which  has  been  mentioned  in  the  literature,  I  have  not  observed. 

The  state  of  the  sensory  reflexes  in  the  course  of  typhoid  fever  has 
hitherto  been  but  little  investigated.  The  literature  contains  but  scanty 
reference  to  the  subject,  and  my  own  observations  also  are  few. 
According  to  these,  the  sensory  reflexes  appear  to  be  generally  much 
diminished  during  profound  coma,  while  in  moderate  and  in  mild 
cases  they  less  commonly  exhibit  alterations.  I  have  frequently  found 
them  normal,  or  diminished  rather  than  increased,  even  in  cases  of 
moderate  severity  showing  marked  tremor. 

Undoubtedly,  considerable  increase  in  the  sensory  reflex  activity 
occasionally  occurs,  and  this  may  persist  for  weeks  and  months  after  the 
attack  of  typhoid  fever,  especially  in  the  lower  extremities,  the  soles  of 
the  feet,  and  the  abdominal  wall.  In  some  patients  the  friction  of  the 
clothing  in  walking,  the  wearing  of  woolen  stockings,  and  the  like, 
give  rise  to  an  annoying  sense  of  tickling.  In  1  case  under  my  obser- 
vation, occurring  in  a  man  who  was  highly  nervous  before  the  attack 
of  typhoid  fever,  there  persisted  such  a  degree  of  general  cutaneous 
hyperesthesia  of  the  lower  half  of  the  body,  with  punctate  anesthesia 
and  exaggeration  of  the  plantar,  cremasteric,  and  abdominal  reflexes, 
that  the  patient  for  a  long  time  could  be  permitted  to  walk  only  when 
a  closely  applied  silk  protective  which  did  not  scratch  the  skin  was 
placed  beneath  the  outer  clothing. 

Diseases  of  the  i^ar/ — The  organ  of  special  sense  by  far  most 
frequently  involved  in  the  course  of  typhoid  fever  is  the  ear.  Among 
1243  cases  of  typhoid  fever  analyzed  by  Bezold,^  impairment  of  hearing 
occurred  in  4  per  cent,  in  the  course  of  the  disease.  Other  aurists  also 
emphasize  the  frequency  of  this  occurrence.  Thus  Biirkner  ^  states  that 
in  1.8  per  cent,  of  all  cases  presenting  impairment  of  hearing,  he  was 
able  to  determine  typhoid  fever  as  the  cause  of  the  disorder ;  while 
Zaufal  found  a  similar  etiologic  factor  in  0.7  per  cent.,  and  Kramer 
in  2.5  per  cent.,  of  their  cases. 

'  See  Moos,  Schwartze's  Handbuch  d.  Ohrenheilkunde.  Bd.  i.  Schwartze,  "  Er- 
krankungen  des  Gehororgans  im  Typhus,"  Deutsch.  Klinik,  1861.  Ibid.,  "  Typhose 
Taubheit,"  etc.,  Arch.  f.  Ohrenh.,  1864  and  1867.  Anatomic  references  can  be  found 
in  the  paper  of  C.  E.  Hoffman,  loc.  cit. 

''■  "  Ueber  die  Erkrankungen  des  Gehororgans  bei  Ileotvphus, "  Arch.  f.  Ohrenh., 
1884. 

^  "Beitrage  zur  Statistik  der  Ohrkrankheiten,"  Arch.  f.  Ohrenh.,  Bd.  xx. 


284  TYPHOID  FEVER. 

The  disorders  of  hearing  tlnis  far  observed  are  most  variable  with 
reference  to  their  seat  and  character.  With  regard  to  the  external  ear 
and  the  auditory  canal,  the  rare  cases  of  gangrene  of  the  auricle  are  to 
be  borne  in  mind  (p.  168).  Periostitis  of  the  external  auditory  canal 
and  perforation  of  abscesses  of  the  ])ar(>tid  aland  into  the  cartilaginous 
portion  of  the  caiial  are  more  frc(|ucnt.  Furunculosis  of  tlic  external 
auditory  canal  is  also  frequently  mentioned.  I  have  observed  it  in  a 
number  of  instances  as  one  of  the  manifestations  of  multiple  furuncu- 
losis of  the  skin  during  convalescence  from  typhoid  fever. 

Among  the  disorders  of  the  internal  car  a  distinction  is  generally 
made  between  purely  nervous  or  functional  disorders  and  those  depend- 
ent upon  organic  causes.     The  purely  functional  disorders  are  by  no 
mciins  rare.     A  portion  of  these  make  their  appearance  at  the  beginning 
of  the  attack,  and  while  they  are  possibly  less  conspicuous  at  the  height 
of  the  disease,  it  is  only  because  the  profoundly  soporose  patients  make 
no  complaint.     Among  these  disturbances  is  to  be  included  especially 
the  extremely  annoying,  subjective  sensation  of  sound,  as  of  roaring  and 
ringing,  which  is  often  present  during  the  first  period  of  the  disease. 
Probably  the  almost  characteristic  impairment  of  hearing  at  the  height 
of  the  disease  is  also  in  many  cases  due  solely  to  nervous  disturbances. 
At  least,  it  is  often  impossible  to  demonstrate  any  causative  lesion  with 
most  thorough  investigation.     The  prognosis  of  these  disorders  is  favor- 
able.    They  disappear  with  subsidence  of  the  fever,  or  at  any  rate  with 
the  end  of  convalescence.     While  formerly  the  causes  of  these  distur- 
bances were  thought  to  consist  in  hyperemia  or  anemia  of  the  brain  and 
its  membranes,  or  even  of  certain  parts  of  the  middle  ear  itself,  at  the 
present  day  the  action  of  toxins  upon  the  parts  in  question  is  properly 
made  responsible. 

The  disorders  of  the  middle  ear  dependent  upon  anatomic  lesions  are 
referable  principally  to  extension  of  inflammatory^  processes  from  the 
structures  of  the  nasopharynx  through  the  Eustachian  tube  to  the 
middle  ear.  Not  rarely  mucopurulent  infectious  matter  gains  entrance 
mechanically  to  the  cavity  of  the  tympanum.  The  possibility  of  dis- 
semination of  excitants  of  inflammation  from  remote  organs  and  their 
lodgment  in  the  ear  is  probably  of  subordinate  significance.  The  micro- 
organisms of  etiologic  significance  in  all  these  inflammatory  processes 
have  not  yet  been  adequately  determined.  Especially  it  has  not  yet 
been  made  out  to  what  extent  the  bacillus  of  Eberth  itself  plays  a  part 
in  this  connection. 

The  course  of  the  affections  of  the  middle  ear  varies  between  the 
mildest  cases  and  those  which  are  the  most  severe  and  are  directly 


SYMPTOMS  AND  COMPLICATIONS.  285 

dangerous  or  are  attended  with  sequelsje  which  persist  throughout  the 
rest  of  life.  For  instance,  purulent  sinus-thrombosis  or  periostitis  and 
caries  of  the  petrous  bone  may  develop.  Fortunately,  these  profound 
disturbances  are  far  less  common  in  the  course  of  typhoid  fever  than 
in  some  other  infectious  diseases,  as,  for  instance,  scarlet  fever  and 
diphtheria.  Far  more  frequent  are  the  milder  disturbances  that  are 
readily  overlooked  in  their  incipiency  unless  the  physician  examines  the 
profoundly  soporose  patient  frequently  and  thoroughly,  and  which  are 
recognized  only  after  they  have  given  rise  to  suppurative  inflamma- 
tion of  the  middle  ear,  with  perforation  of  the  drum-membrane  and 
otorrhea.  In  addition  to  inflammatory  lesions  of  the  middle  ear,  hemor- 
rhages into  the  cochlea  and  the  vestibule  have  been  observed  as  the 
cause  of  severe,  and  at  times  permanent,  impairment  of  hearing. 
Moos '  also  mentions  small-cell  infiltration  of  the  membranous  laby- 
rinth. 

Disorders  of  the  Byes.^ — These  are,  on  the  whole,  rare  in  cases 
of  typhoid  fever  ;  at  any  rate,  they  are  much  less  common  than  diseases 
of  the  ear.  Gangrene  of  the  tissues  has  exceptionally  been  observed 
in  the  immediate  vicinity  of  the  eyes  and  of  the  lids,  and  has  been 
attributed  to  endarteritis  and  thrombosis  of  the  external  carotid  artery 
and  its  branches  (p.  168).  True  noma  complicating  typhoid  fever  ls 
also  mentioned  by  earlier  writers  as  a  cause  for  extensive  destruction  of 
the  eyelids. 

Paralysis  of  the  extra-ocular  muscles  occurs  most  commonly  during 
convalescence.  Knies  believes  that  certain  varieties  of  these  extra- 
ocular paralyses  are  nuclear  in  origin  and  are  to  be  attributed  to  a 
chronic  nephritis.  Unilateral  and  bilateral  ptosis  has  been  observed 
(Nothnagel,  Henock).  Cases  occurring  during  the  height  of  the  fever 
are  very  rare  in  the  absence  of  intracranial  complications.  Ptosis  and 
abducens  palsy  have  been  recorded  in  the  third  week  of  the  disease  by 
Nothnagel.  In  a  case  at  the  Johns  Hopkins  Hospital  oculomotor 
paresis  of  the  left  eye  developed  on  the  eighth  day  of  the  disease.  In 
this  case  there  was  paralysis  of  both  intra-ocular  and  extra-ocular 
muscles,  and  the  condition  was  probably  due  to  a  slight  local  menin- 
gitis.    In  children  symptoms  of  meningitis  and  strabismus  may  occur 

^  Loc.  cit. 

*  See  Forster,  Beziehungen  der  Allgemeinleiden  und  Organerkrankiingen  zii  Verdn- 
derungen  und  Krankheiten  des  Sehorganes,  Leipsic,  1877  ;  and  Knies,  Die  BezieJumgen 
des  Sehorganes  und  seiner  Erkrankungen  zu  den  iibrigen  Krankheiten  des  Korpers  und 
seijier  Organe^  Wiesbaden,  1893.  Also,  de  Schweinitz,  chapter  on  "  Ocular  Compli- 
cations "  in  The  Surgical  Com,plicatio7is  and  Sequels  of  Typhoid  Fever  by  Keen,  Phila., 
1898,  Phila.  Med.  Jour.,  March  3,  1900. 


286  TYPHOID  FEVER. 

early,  but  it  is  questionable  ^vhether  they  are  associated  with  a  true 
meningeal  inflammation. 

Paralysis  of  the  intra-ocular  muscles  is  also  most  common  during 
convalescence.  Forster,  with  whom  Knies  agrees,  considers  the  paral- 
ysis of  accommodation  and  mydriasis  as  essentially  part  manifestations 
of  the  genei'al  exhaustion  ;  far  less  frequently  they  are  due  to  circum- 
scribed disease  of  the  affected  nerve-paths. 

Among  the  changes  in  the  eyeball  itself,  conjunctivitis  should  first 
be  mentioned.  A  catarrhal  form  of  conjunctivitis  occurs  frequently  in 
deeply  soporose  patients  during  the  febrile  period,  but  by  no  means  so 
frequently  as  typhus  fever  and  small-pox,  or  even  measles.  Probably 
this  conjunctivitis  is  not  specific,  but  is  dependent  upon  or  favored  by 
the  fact  that  the  duD  patient  winks  infrequently  and  closes  his  eyes 
imperfectly  and  possibly  also  by  the  diminished  secretion  of  tears. 
During  convalescence,  and  sometimes  in  the  later  stages  of  the  disease, 
a  true  phlyctenular  conjunctivitis  may  appear.  A  phlyctenule  may 
break  down  and  form  an  ulcer,  or  without  this  origin  ulcerative  keratitis 
may  arise.  These  ulcers  are  rarely  so  large  as  to  give  rise  to  extensive 
leukoma  and  considerable  impairment  of  vision.  True  keratomalacia, 
which  was  early  described  by  Trousseau,  is,  fortunately,  an  extremely 
rare  manifestation  of  profound  marantic  or  septic  conditions  (see  my 
own  case,  pp.  291  and  292).  According  to  Knies,  iritis,  cyclitis, 
choroiditis,  and  chorioretinitis  also  occur ;  less  commonly,  however,  than 
in  other  infectious  diseases,  as,  for  instance,  relapsing  fever.  They 
may  give  rise  to  permanent  profound  impairment  of  vision,  as  the  cases 
of  Arens  and  Tr^lat,  cited  by  Knies,  show. 

Though  extremely  rare,  the  transitory  and  the  permanent  forms  of 
amaurosis  are  worthy  of  mention.  The  transitory  forms,  whose  nature 
and  causes  have  not  been  adequately  studied,  occur  almost  solely 
in  youth  and  childhood  (Eberth,  Nagel,  Fr^minau,  Forster).  I  have 
personally  observed  such  a  case  develop  in  a  girl,  eleven  years  old, 
without  demonstrable  lesion  of  the  eye-ground,  in  the  course  of  typhoid 
nephritis,  and  disappear  within  seventy-two  hours  without  leaving  a 
trace.  Uremia  must  be  thought  of  as  the  cause  in  such  cases.  The 
persistent  forms  of  amaurosis,^  which  may  be  either  unilateral  or  bilat- 
eral, generally  depend  upon  atrophy  of  the  optic  ner\^e.  The  seat  of 
the  disturbance  is  to  be  sought  either  in  the  brain  or  in  the  optic  tract 
itself.  Among  the  causes  of  the  disturbances  in  question,  hemorrhage 
and  sclerotic  or  other  variety  of  focal  disease  have  been  mentioned. 
Probably  meningitic  exudates,  with  their  injurious  secondary  effects, 
1  The  literature  is  given  by  Forster. 


•      VARIATIONS  IN  SYMPTOMS  AND  COURSE.  287 

are  also  often  operative,  as  Knies  and  Forster,  especially,  have  pointed 
out. 

Optic  neuritis  during  typhoid  is  usually  associated  with  meningitis. 
However,  according  to  de  Schweinitz,  an  optic  neuritis  may  occur 
which  is  entirely  unconnected  with  intracranial  complications,  and 
is  analogous  to  the  neuritis  occurring  in  the  nerves  elsewhere  in  the 
body. 

According  to  Bull,  retinal  hemorrhages  are  not  infrequent  during 
the  height  of  typhoid  fever,  being  most  common  about  the  third  week. 
A  perverted  quality  of  the  blood,  a  weakened  condition  of  the  blood- 
vessel walls,  or  a  microbic  invasion  of  the  vascular  coats  may  explain 
these  hemorrhages  (de  Schweinitz). 

VARIATIONS  IN  SYMPTOMATOLOGY  AND  COURSE, 

The  character  and  the  severity  of  the  course,  and  the  symptomatology, 
of  typhoid  fever  represent  the  expression  of  two  principal  factors, 
namely,  the  mode  of  action  of  the  bacillus  of  Eberth  upon  the  body, 
particularly  the  degree  of  its  virulence ;  and  the  special  conditions  of 
the  invaded  organism  itself.  These  conditions  are,  naturally,  extremely 
variable.  As  to  the  nature  of  these  conditions,  a  part  is  already 
known,  at  least  empirically,  while  a  part  is  still  entirely  undetermined. 
Among  the  more  important  determining  conditions  are,  first,  the  factors 
relating  to  individual,  namely,  age,  sex,  constitution,  occupation,  and 
mode  of  life,  and  the  degree  of  susceptibility  and  power  of  reaction. 
Further,  of  importance  in  shaping  the  cause  of  the  disease  are  special 
prominence  of  symptoms  on  the  part  of  individual  organs  or  systems, 
and  the  not  uncommon  associated  activity  of  the  typhoid-bacillus  with 
other  pathogenic  micro-organisms.  In  addition  to  the  special  condi- 
tions, general  conditions  also  play  a  role,  and  these  aflFect  the  indi- 
vidual only  in  part,  but  in  far  greater  degree  influence  the  preservation, 
development,  dissemination,  and  the  degree  of  virulence  of  the  virus ; 
these  are  especially  the  local  conditions,  habitations,  state  of  cultivation, 
modes  of  intercourse,  and  water-supply,  and,  finally,  the  geographic 
situation,  climate,  and  season.  The  varieties  of  clinical  picture,  course, 
and  termination  of  typhoid  fever  resulting  from  all  these  various 
influences  are  so  diverse,  often  so  completely  opposed,  and,  on  the 
other  hand,  at  times  so  running  together,  that  any  exhaustive  descrip- 
tion is  impossible.  Every  case,  therefore,  is  difl'erent  from  everv  other, 
and  any  description  can  serve  only  as  a  guide  in  the  midst  of  this 
variability,    and  determine    the    most    important    points    of  view.     A 


288  TYPHOID  FEVER. 

considerable  number  of  facts  in  this  connection  have  already  been 
referred  to  in  the  clinical  section. 

It  will  be  best  to  be^iu  the  description  with  a  recital  of  the  simplest 
conditions :  the  varieties  of  typhoid  fever  that  result  in  accordance 
with  the  severity  and  the  mildness  of  the  attack,  as  well  as  those 
varieties  depending  upon  the  duration  of  the  disease  in  general,  or  of 
its  different  stages.  It  may  be  emphasized  in  advance  that  severity 
and  long  duration  of  the  disease  do  not  coincide  any  more  than  do 
brevity  and  mildness.  Although  such  coincidence  occurs  frequently 
in  the  individual  case,  the  severity  and  the  duration  of  the  symptoms 
are,  in  general,  wholly  independent  of  each  other.  The  best  evidence 
of  this  is  afforded  by  the  study  of  the  variety  to  be  described  first. 

The  Siiort,  Malignant  Variety  {Malignant  or  Fulminant 
Typhoid  Fever  ;  Hyperpyretic  Variety). — This  variety,  which,  fortunately, 
is  rare,  represents,  as  its  designations  indicate,  a  form  of  typhoid  fever 
of  most  severe  course.  Some  of  the  cases  begin  after  a  longer  or 
shorter  period  of  incubation,  which  is  not  free  from  symptoms.  The 
patients  complain  for  days  in  advance  of  great  malaise,  headache, 
vertigo,  and  sleeplessness,  and  often  exhibit  nausea  and  vomiting,  and 
not  rarely  diarrhea.  The  pulse,  also,  at  this  time  may  be  abnormally 
frequent,  and  the  temperature  temporarily  elevated.  In  another  group 
of  cases  the  disease  sets  in  suddenly,  without  prodromal  manifestations, 
with  a  single  chill  or  repeated  severe  chilliness. 

Almost  always  the  stage  of  ascending  fever  is  considerably  shortened, 
so  that  within  from  twenty-four  to  forty-eight  hours  the  level  of  con- 
stant fever  is  reached.  At  times  this  occurs  at  once,  at  other  times 
with  one  or  two  slight  remissions.  The  temperature-level  then  reached 
is  not  rarely  an  unusual  one,  so  that  as  early  as  the  evening  of  the 
second  to  the  fourth  day  of  the  disease  the  thermometer  may  register 
from  40.5°  to  41°  C.  (Fig.  14).  The  temperature  then  remains  at 
this  level,  generally  with  slight  fluctuations,  for  the  next  few  days,  or  it 
rises  still  higher,  preserving  the  character  of  a  continued  or  remittent 
continued  fever  (Fig.  25). 

The  pulse,  even  in  robust  men,  is  from  the  outset  excessively  fre- 
quent, at  first  still  full  and  tense.  Soon  it  becomes  softer  and  dicrotic. 
The  differences  between  the  morning  and  evening  pulse-frequency  are, 
like  those  in  the  temperature,  remarkably  slight.  Shortly  before  or  at 
the  height  of  the  fever,  at  times  even  during  the  ascent,  the  patients 
become  stupid.  They  are  delirious  at  night  and  sometimes  by  day,  and 
lie  in  a  state  of  relaxation,  in  passive  dorsal  decubitus,  with  the  mouth 
open,  exposing  the  dry,  fissured  tongue  and  lips.     Subsultus  tendinum,. 


VARIATIONS  IN  SYMPTOMS  AND   COUIISE. 


289 


floctitation,  and  grinding  of  the  teeth,  in  young  persons  even  convul- 
sions, increase  the  gravity  of  the  clinical  picture.  Not  rarely  rigidity 
of  the  back  with  opisthotonos  and  other  cerebrospinal  symptoms  are 
present  besides. 

The  state  of  the  spleen  is  variable.  Generally  it  is  distinctly  demon- 
strable quite  early,  even  at  the  time  of  admission  of  the  patient,  on  the 
second  or  the  third  day  of  the  disease,  and  often  the  organ  is  converted 
into  a  large,  soft,  and  sensitive  tumor.  Less  commonly  enlargement  of 
the  spleen  occurs  later,  or  is  not  demonstrable  throughout  the  entire 
course  of  the  attack.     The  abdomen  early  becomes  greatly  distended. 

Day  of  the  Disease. 


60 


40 


20 


DO 


30 


BO   35 


^^^^ 


y^- 


r. 


38 


Fig.  25.— Temperature-chart  from  a  fulminant  ease  of  typhoid  fever  in  a  woman,  thirty-five 
years  old,  terminatidfe  fatally  on  the  eighth  day.  This  was  the  third  case  in  a  house-endemic. 
The  attack  began  with  a  chill.  Intestinal  lesions  were  marked,  especially  in  the  region  of  the 
cecum  and  the  lower  third  of  the  ileum.  Peyer's  patches  were  in  a  state  of  medullary  swelling, 
in  part  greatly  disintegrated,  and  in  a  state  of  congestion.    No  complication  was  present. 


and  in  some  cases  acquires  a  considerable  degree  of  tension,  which  is  an 
ominous  sign.  The  stools  are  at  times  diarrheal,  at  other  times  con- 
stipated ;  the  urine  generally  contains  albumin  during  the  first  few  davs, 
at  the  same  time  being  scanty,  concentrated,  and  high-colored.  While 
ischuria  occurs  at  first,  with  the  commencement  of  deep  stupor,  the 
urine  and  the  stools  are  passed  involuntarily  into  the  bed. 

The  termination  is  in  most  cases  fatal,  following  progressive  loss  of 
strength,  and  at  times  associated  with  extremely  high  degrees  of  tem- 
perature (hyperpyretic  form).  Only  the  minority  of  patients  survive. 
In  the  latter  event  the  severity  of  the  general  symptoms  subsides  toward 
the  end  of  the  second  week,  the  temperature-curve  declines  to  a  lower 

19 


290  TYPHOID  FEVER. 

level,  with  simultaneous  improvement  in  the  pulse ;  and  after  a  longer 
or  shorter  period  the  patient  becomes  afebrile.  Convalescence  is  always 
unusually  severe  and  protracted ;  this  often  occurs  in  consequence  of 
recrudescences  and  relapses. 

The  symptoms  in  the  presence  of  which  death  takes  place  are  those 
of  most  profound  intoxication.  Only  exceptionally  do  early  intercur- 
rent intestinal  hemorrhages  accelerate  the  fatal  termination.  Post- 
mortem exammation  discloses,  in  accordance  with  the  short  duration 
of  the  attack,  that  the  lesions  in  the  small  and  the  large  intestine  are 
still  in  a  state  of  medullary  swelling,  and  only  here  and  there  is  there 
beginning  sloughmg.  Their  extent  and  intensity  do  not,  by  any  means, 
always  correspond  with  the  severity  of  the  clinical  picture.  Although 
severe  degrees  of  intestinal  involvement  are  more  frequent,  cases  also 
occur  with  remarkably  slight  specific  intestinal  lesions.  The  large, 
soft,  diffluent  spleen  is  often  the  seat  of  recent  extravasations  of  blood. 
The  liver  and  the  kidneys  are  in  a  state  of  marked  cloudy  swelling. 
Fortunately,  as  has  been  stated,  this  variety  is  quite  rare.  It  occurs 
principally  in  adults  up  to  the  fortieth  year,  while  children  and  old 
persons  are  attacked  much  less  frequently.  With  reference  to  the 
duration  of  the  process,  the  fulminant  form,  which  may  terminate 
fatally  at  the  end  of  the  first  week,  and  rarely  persists  until  the  end 
of  the  second,  is  to  be  contrasted  with  the  severe  forms  of  protracted 
course. 

Severe  and  Moderately  Severe  Cases  of  Protracted 
Course. — Detailed  reference  need  not  again  be  made  here  to  the 
course  of  such  cases,  as  this  has  been  fully  done  previously  (General 
Clinical  Picture).  At  this  place  we  wish  merely  to  point  out  that  the 
conditions  and  the  forms  of  the  prolonged  attack  are  extremely  variable. 
Thus,  the  prolongation  may  be  due  to  the  fact  that  the  individual  stages 
of  the  disease  are  extended  beyond  the  usual  period.  This  applies  with 
especial  frequency  to  the  fastigium,  which  may  persist  for  as  long  as 
four  weeks,  and  even  much  longer.  The  fever  has  then  less  commonly 
or  only  in  the  first  stage  the  character  of  a  continued  or  remittent  con- 
tinued type.  Very  early  or  even  from  the  outset,  the  temperature  is 
likely  to  exhibit  marked  fluctuations,  and  may  assume  the  character 
of  an  intermittent  type  or  even  become  wholly  irregular.  Next  in 
frequency  the  stage  of  defervescence  is  prolonged.  The  characteristic 
steep  curves  are  then  obscured  or  are  entirely  absent,  and  the  increase 
in  temperature  takes  place  gradually,  with  a  more  or  less  protracted, 
remittent,  or  wholly  irregular  course,  in  which  there  are  not  infrequently 
causeless  remissions  and  exacerbations.     After  defervescence  has  finally 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  291 

taken  place,  the  stage  of  convalescence  may  be  unusually  long.  The 
patients  remain  weak,  and  often  exhibit  marked  instability  of  pulse  and 
temperature,  so  that  transitory  increase  may  take  place  without  obvious 
cause  or  upon  slight  provocation.  Cases  are  also  frequent  in  which 
convalescence  is  unusually  prolonged  in  consequence  of  recrudescences 
and  relapses  (recrudescent  form). 

The  moderately  severe  and  mild  forms  may,  not  less  than  the  severe 
form,  be  unduly  protracted,  and  yet  give  no  cause  for  especial  anxiety 
at  any  time  in  the  course  of  the  attack.  The  fever  is  then  from  the 
outset  not  very  high,  and  is  quite  irregular  or  remittent,  or  so  markedly 
intermittent  fromi  the  beginning  that  the  temperature-chart  in  conse- 
quence acquires  an  appearance  which  seems  remarkable  to  the  inexperi- 
enced observer,  and  may  readily  give  rise  to  false  conclusions.  These 
cases  are  also  frequently  prolonged  by  recrudescences  and  relapses, 
which,  in  course  and  intensity,  resemble  the  primary  attack  or  are  even 
more  severe.  While  severe  and  moderately  severe  cases  generally 
pursue  their  course  in  from  four  to  five  weeks,  protracted  cases  may 
keep  the  patient  in  bed  for  from  three  to  four  months,  and  even  longer. 

Among  these  protracted  cases,  those  terminating  fatally  from  maras- 
mus, which  fortunately  are  of  extreme  rarity,  are  deserving  of  special 
mention.  In  these  cases  the  disease,  which  is  generally  severe  from  the 
outset,  is  then  prolonged  unduly,  there  is  often  an  irregular  temperature- 
curve,  and  when  defervescence  has  finally  taken  place,  the  patients  do 
not  convalesce,  but  their  condition  becomes  progressively  worse.  The 
appetite  is  not  restored,  but,  on  the  contrary,  there  is  distaste  for  food, 
especially  for  meat,  bouillon,  and  milk.  Some  patients  who  eat  even 
fairly  well  fail,  nevertheless,  to  make  progress.  The  bowels  are  consti- 
pated in  all  these  cases ;  the  abdomen  is  hard  and  retracted.  The 
skin  appears  dry  and  scaly,  and  the  hands  and  feet  are  cyanotic  and 
cold.  Emaciation  progresses  uninterruptedly,  although  most  careful 
examination  fails  to  disclose  any  special  organic  lesion,  and  life  is  ter- 
minated with  the  most  profound  marasmus.  Post-mortem  examination 
in  such  cases  discloses  what  clinical  examination  had  already  rendered 
probable,  namely,  the  absence  of  complications  or  any  special  organic 
change.  Murchison,  who  directed  especial  attention  to  this  form  of 
the  disease,  states  that  Rokitansky  attributed  it  to  shrinking  of  the 
mesenteric  glands,  together  with  disappearance  of  the  intestinal  villi 
and  lymph-follicles. 

A  characteristic  case  of  this  remarkable  variety,  to  which  even  experi- 
enced clinicians  make  no  reference,  came  under  my  observation  in  con- 
sultation, occurring  in  a  girl  twenty-one  years  old,  who  lived  amid  the  most 


292  TYPHOID  FEVER. 

favorable  couditions.  After  an  attack  of  typhoid  fever  of  eleven  weeks' 
duration,  Nvitb  irregular  and  on  the  whole  low  fever,  the  patient  appeared 
about  to  enter  upon  convalescence.  The  temperature  became  subnormal,  and 
soon  reached  an  unusually  low  level — 33.5°  or  34°  C.  in  tlie  morning.  The 
pulse  remained  unusually  small,  thready,  and  retarded,  and  became  progres- 
sively slower,  so  that  finally  only  38  or  40  beats  could  be  counted  in  the 
minute.  At  the  same  time  the  patient  wasted  in  a  frightful  manner,  and 
upon  the  thin  skin  stretched  over  the  bones  bed-sores  gradually  appeared 
in  the  most  varied  situations — over  the  sacrum,  the  vertebra?,  at  the  heel, 
even  over  the  iliac  spine,  the  upper  extremity  of  the  fibula,  and  the  ankles ; 
ancV  after  suffering  for  a  long  time,  the  patient  finally  died,  total  necrosis 
of  the  left  and  beginning  necrosis  of  the  right  cornea  having  also  developed 
in  the  last  few  days  of  life.  At  the  autopsy  there  was  no  noteworthy  altera- 
tion of  the  internal  viscera,  with  the  exception  of  the  intestine,  which  con- 
tained numerous  smooth,  pigmented  cicatrices  in  the  ascending  colon,  and 
in  the  ileum  in  the  vicinity  of  the  ileocecal  valve,  in  place  of  the  Peyer's 
patches,  so  that  even  the  pathologic  anatomy  was  unable  to  answer  the 
question  as  to  the  cause  of  death. 

Well-characterii?ed  Cases  Pursuing-  a  Moderate  and 
Mild  Course. — While  definite  external  or  individual  conditions  or 
special  organic  disease  often  give  their  impress  to  cases  of  this  group, 
they  are  in  general  distinguished  from  one  another  principally  by  their 
duration.  In  a  number  of  the  cases  the  duration  is  shorter  than  is 
the  average  in  the  well-marked  severe  cases,  while  others  pursue  equally 
as  long  but  a  mild  course.  Among  the  cases  of  the  first  kind,  those 
are  especially  characteristic  in  which  the  individual  stages  of  the  disease 
are  regular  and  maintain  their  normal  proportions,  although  they  are 
shorter,  so  that  the  temperature-chart,  except  as  to  the  duration  of  the 
various  stages,  entirely  resembles  that  of  the  typical  variety  (Fig.  11). 
Other  cases  exhibit  a  favorable  course  in  that  certain  individual  stages 
of  the  disease  are  considerably  shortened  or  remain  almost  undeveloped. 
Thus,  the  initial  stage  may  be  almost  entirely  wanting,  and  the  height 
of  the  fever  may  be  reached  at  a  single  bound  in  from  twelve  to  eighteen 
hours ;  or,  as  occurs  with  especial  frequency,  the  stage  of  steep  curves 
is  considerably  shortened  or  is  not  at  all  marked.  In  the  latter  event 
the  febrile  stage  is  often  terminated  by  a  critical  decline.  Consider- 
able shortening  of  the  amphibolic  stage,  with  complete  development  of 
the  initial  period  and  that  of  convalescence,  is  less  common. 

The  cases  of  moderate  and  mild  degree,  which  are  unabbreviated, 
but,  on  the  contrary,  are  often  greatly  prolonged,  appear  to  pursue  a 
whollv  irregular  course.  Under  these  circumstances  the  febrile  stage 
maintains  in  general  a  lower  temperature-level.  The  curs'e  is  at  the 
same  time  likely  to  exhibit  a  markedly  remittent  or  wholly  irregular 
course.     The  general  symptoms  are  likely  to  be  exceedingly  mild,  and 


VARIATIONS  IN  SYMPTOMS  AND   COURSE.  293 

the  nervous  system  especially  is  but  little  invf^lved.  From  the  diag- 
nostic point  of  view,  these  eases,  apart  from  the  fact  that  the  fever- 
curve  frequently  gives  no  aid,  may  further  be  a  source  of  considerable 
difficulty  because  of  the  absence  of  splenic  enlargement  or  its  unusually 
late  development,  because  of  the  scantiness  of  the  roseolae,  or  inability  to 
demonstrate  them,  throughout  the  entire  course  of  the  disease,  and  occa- 
sionally also  because  of  the  insignificant  character  of  the  intestinal 
symptoms.  Such  cases  are  probably  the  same  as  those  that  earlier 
physicians  designated  as  gastric  fever  or  as  mucous  fever,  and  separated 
etiologically  from  typhoid  fever.  It  is  only  a  step  from  these  moderate 
and  mild  cases  to  those  pursuing  an  especially  short  and  frequently 
also  an  especially  mild  course.  These  are  really  separable  only  super- 
ficially, for  they  are  actually  connected  by  all  possible  transitional 
forms. 

Atypical  Cases  of  very  Short  and  Mild  Course  [Typhus 
Abortivus,  Typhus  Levissimus,  Typhoidette  {Brouardeiy — In  earlier  times 
these  cases  were,  still  less  than  the  preceding  forms,  considered  as  exam- 
ples of  typhoid  fever.  Although  Lebert  ^  occupied  himself  with  their 
study  and  contributed  something  to  the  knowledge  of  them,  it  remained 
for  Griessinger^  to  demonstrate  beyond  doubt  their  nature  and  their 
relation  to  typhoid  fever.  He  was  followed  by  Jiirgensen,^  Baumler,* 
and  others,  who  helped  to  give  clearness  and  force  to  the  new  doctrine. 
All  the  cases  included  in  this  group  are  characterized  by  the  especial 
shortness  of  the  course,  and  frequently  also  by  the  marked  mildness. 
Mildness  is,  however,  as  has  been  mentioned,  by  no  means  always  a 
characteristic  feature.  On  the  contrary,  the  well-developed  cases  may. 
be  classified,  according  to  the  suggestion  of  Liebermeister,  into  mildest 
cases  (Typhus  levissimus),  including  all  cases  characterized  by  mild- 
ness and  by  brevity,  and  into  a  second  class  (Typhus  abortivus),  which 
includes  those  cases  in  which,  although  the  course  is  short,  the  character 
of  the  disease  may  at  times  be  quite  severe  and  even  alarming. 

If  the  manner  in  which  the  mild  and  the  abortive  cases  of  typhoid 
fever  make  their  appearance  be  more  minutely  observed,  it  will  be 
found  that  they  exhibit  in  varying  degree  the  evidences  of  imperfect 
development  of  the  disease.  We  have  observed  that  in  the  mild  cases 
one  or  another  stage  of  the  disease  is  often  abbreviated,  but  in  the 
cases  under  consideration  this  shortening  often  attains  a  most  extreme 

1  Prag.   Viertelj.,  1857,  Bd.  Ivi. 

'Schmidt,  Inaug.  Diss.,  Zurich,  1862;  and  InfeJitionskrankheiten,  1864. 

■"  Volkmann' s  Sammlung  klin.   Vortr.,  1873,  No.  61. 

*  Dublin  Med.  Jour.,  Nov.,  1880;  and  Deutsch.  Arch.  f.  kliyi.  Med.,  Bd.  iii. 


294 


TYPHOID  FEVER. 


Day  of  the  disease. 


degree.  All  the  stages  may  be  considerably  shortened  in  their  course 
or  may  be  so  abridged  us  to  be  unrecognizable.  As  in  the  cases  of 
moderate  severity,  so  also  in  the  mildest,  this  abbreviation  may  affect 
the  initial  and  the  terminal  stages  especially,  sometimes  in  the  form 
of  an  abrupt  rise  or  a  critical  decline,  or  there  may  be  a  quite  gradual 
commencement  or  subsidence  of  the  fever.  It  should  be  pointed  out 
that  considerable  shortening  of  the  initial  stage  and  critical  decline  of 
the  fever  occur  more  frequently  in  cases  of  abortive  typhoid  than  in 
those  of  the  mildest  variety.  The  fastigium  of  the  disease,  which  like- 
wise is  frequently  more  or  less  greatly  shortened,  may  exhibit  all 
possible  varieties  of  temperature-curve,  from  that  of  the  regular  remit- 
tent continued  course,  which  is  decidedly  the  least  common,  to  that  of 
the  pure  intermittent  or  wholly  irregular  course,  with  low  or  moderate 
temperature. 

The  pulse  is  likely  to  be  particularly  accelerated  and  to  be  unstable 
onlv  in  irritable  women  and  children,  while  in  less  sensitive,  more 
robust  individuals  it  exhibits  scarcely  any  acceleration  throughout  the 
entire   course   of   the  disease.      Even  in  the  abortive  cases   with  high 

temperature  at  the  outset,  the 
slight  degree  of  increase  in 
the  frequency  of  the  pulse  is 
at  times  especially  striking 
(Fig.  29). 

Before  passing  to  a  con- 
sideration of  the  remaining 
symptoms  of  the  abbreviated 
and  the  mildest  cases,  a  few 
histories  with  temperature- 
tracings  may  be  briefly  given 
to  illustrate  the  various  forms 
of  course. 

The  following  case  may  be 
coiisidei'ed  as  one  of  abortive 
typhoid  fever :  A  compositor, 
nineteen  years  old,  after  several 
davs  of  headache,  anorexia,  and 
prostration,  was  suddenly  seized 
with  a  chill.  On  the  day  of  ad- 
mission ("second  day  of  the  disease;  enlaro-emeut  of  the  spleen  was  distinctly 
demonstrable.  Between  the  fourth  and  the  fifth  day  a  small  number  of 
roseolse  made  their  appearance  upon  the  chest,  the  abdomen,  and  the  back, 
and  were  followed  by  others  up  to  the  ninth  day.  On  the  second  day  of  the 
disease  the  evening  temperature  was  40.2°  C,  and  from  this  time  on  until  the 


VARIATIONS  IN  SYMPTOMS  AND   COURSE. 


295 


sixth  day,  on  which  the  evening  temperature  reached  40.6°  C,  there  was 
comparatively  high  continued  fever,  which  then  declined  rapidly  in  two 
stages,  and  complete  defervescence  occurred  after  the  eighth  or  the  ninth 
day  (Fig.  26).  The  pulse  during  the  febrile  period  ranged  between  100 
and  120,  and  was  full  and  of  high  tension.  Convalescence  was  uncompli- 
cated, and  the  patient  was  dismissed  after  three  and  one-half  weeks  ready  to 
return  to  work. 

The  temperature-chart  shown  in  Fig.  27  is  from  a  case  with  nine  days  of 
fever,  on  only  two  or  three  of  which  the  temperature  was  high,  but  which, 
nevertheless,  exhibited  a  severe,  even  alarming,  aspect.  The  patient  was  an 
obese  assessor,  thirty -six  years  old,  who  had  drunk  a  good  deal  of  beer  and 
had  eaten  generously,  though  engaged  in  but  slight  physical  activity.  He  was 
seized  with  a  chill  on  a  return  journey  from  Italy.  As  early  as  the  second  day 
of  the  disease  a  large,  palpable,  sensitive,  splenic  tumor  was  present ;  on  the 
third  day,  an  abundance  of  roseolse  on  the  trunk,  the  upper  arms,  and  the 


Day  of  the  disease. 


Fig.  27. 

thighs.  From  this  day  on  there  were  stupor  and,  toward  evening  and  in  the 
night,  active  delirium  with  attempts  at  flight.  From  the  fourth  to  the  tenth 
day  there  was  moderate  albuminuria,  at  first  even  with  slight  admixture  of 
hlood  and  of  hyaline  and  epithelial  casts,  and  a  small  number  of  blood- 
casts.  As  will  be  seen  from  the  temperature-chart,  the  fever  subsided  grad- 
ually. Complete  defervescence  was  attained  between  the  night  of  the  eighth 
and  the  morning  of  the  ninth  day  by  a  sort  of  critical  decline,  which  was 
attended  with  profuse  sweating.  The  state  of  the  pulse  was  from  the  out- 
set quite  favorable,  being  intermittent  now  and  aeain  during  the  first  few 
days,  but  never  especially  small  or  frequent.  Convalescence  was  unusu- 
ally protracted,  so  that  the  patient,  in  spite  of  the  short  duration  of  the 
actual  febrile  stage,  was  not  able  to  get  out  of  bed  until  after  four  and 
one-half  weeks,  and  then  with  a  loss  of  weight  of  19  pounds. 

By  the  side  of  this  case  may  be  placed  that  from  which  the  tracing 
shown  in  Fig.  28  was  obtained.  This  occurred  in  an  embroiderer,  twenty- 
one  years  old,  who  was  admitted  on  the  fourth  day  of  the  disease,  and  entered 


296 


TYPHOID  FEVER. 


upon  defervescence  on  the  thirteenth  day.  The  clinical  picture  was  severe 
until  the  eleventh  day  of  the  fever,  with  marked  apathy,  somnolence,  and 
slight  tlelirium.  The  course  of  the  temperature  exhihiteil  the  character  of  a 
rather  ohstinate,  remittent,  continued  fever  of  moderate  degree.  Systematic 
treatment  with  haths  was  required,  the  etfect  of  which  was  hut  slight  and  of 
short  duration.  On  admission  a  large  ])alpal)le  splenic  tumor  was  ])resent, 
and — what  made  this  case  appear  especially  remarkahle — there  was  an 
unusually  profuse  eruption  of  roseola?,  which  continued  to  multiply  until 
the  evening  of  the  fifth  day,  so  that  as  many  as  700  could  be  counted  upon 
the  back  and  the  extremities.  The  pulse  remained  relatively  good,  even 
at  the  height  of  the  fever,  being  always  full,  regular,  and  tense,  hut  being 
more  than  120  only  on  the  first  evening,  and  thereafter  ranging  about  100 
and  below. 

The  following  case  exhibits  a  certain  contrast  to  the  2  severe  cases  just 
mentioned  ;   it  likewise  was  attended  with  fever  of  moderate  degree,  but  it 

Dav  iif  the  disease. 


Fig.  28. 


did  not  for  an  hour  exhibit  any  severe  or  alarming  symptoms  even  at  the 
height  of  the  disease.  It  occurred  in  an  extremely  robust  hostler,  twenty 
years  old.  The  fever  lasted  altogether  for  nine  days,  the  markedly  remit- 
tent and  intermittent  curve  rising  generally  in  the  evening  to  from  39°  to 
39.7°  C,  and  finally  exhibiting  a  peculiar  and  rare  variety  of  critical  decline 
in  two  stages.  Between  the  ninth  and  the  tenth  day  the  temperature  fell 
from  39°  to  37°  C,  then  fluctuated  for  two  days  between  37°  and  37.6°  C,  to 
decline  again  suddenly  below  normal  between  the  eleventh  and  twelfth  days, 
and  persisting  at  this  low  level  during  the  first  part  of  convalescence  (Fig. 
29).  As  the  temperature-chart  shows,  the  pulse  in  this  case  was  from  the 
outset  unusually  slow,  although  always  full  and  tense  ;  at  no  time  was  the 
sensorium  of  the  patient  in  any  degree  affected,  and  he  complained  of  hunger 
even  before  the  subsidence  of  the  fever  ;  after  a  brief,  uninterrupted  con- 
valescence he  was  restored  to  his  full  capacity  for  work  with  remarkable 
rapidity. 

The  following  case  pursued,  on  the  whole,  a  severe  course,  with  various 


VABIATIONS  IN  SYMPTOMS  AND   COURSE. 


297 


Diiv  of  til''  disofisf. 


Fig.  29. 


subjective  complaints  and  for  days  a  small,  although  not  unduly  frequent, 
pulse.     This  is  an  example  of  almost  complete  intermittence  of  the  tempera- 


Day  of  the  disease. 


ture-curve  from  the  first  day  of  observation,  and  probably  from  the  beginning 
of  the  fever  (Fig.  30).  The  patient  was  a  girl,  fifteen  years  old,  in  whom 
enlargement  of  the  spleen  was  demonstrable  on  the  fifth  day,  with  moderate 


298 


TYPHOID  FEVER. 


distention  of  the  abtlonien  and  slight  tenderness  in  the  ileocecal  region,  and 
from  the  seventh  to  the  thirteenth  day  two  or  three  thin,  pea-soup-like 
stools  were  passed  daily.  The  mother  of  the  patient  had  died  shortly 
before  from  an  attack  of  the  gravest  form  of  typhoid  fever,  with  intestinal 
hemorrhage. 

The  following  case  will  serve  as  an  example  of  true  typhoid  fever  of  the 
mildest  type.  The  patient  was  a  man,  forty-one  years  old,  who  had  been 
under  treatment  in  the  hospital  for  months  for  tabes  dorsalis,  but  otherwise 
he  was  robust  and  well  nourished.  The  onset  of  the  disease,  which  was  not 
preceded  by  prodromes,  was  attended  with  chilliness.  As  early  as  the  first 
day  enlargement  of  the  spleen  was  demonstrable  by  percussion,  and  on  the 
third  day  as  well  by  palpation.  A  small  numl)er  of  well-developed  roseolse 
appeared  relatively  late — between  the  sixth  and  the  ninth  day.  Through- 
out the  entire  course  of  the  disease  there  was  no  diarrhea,  but,  on  the  con- 
trary, constipation.     Convalescence  progressed  rapidly,  and  at  its  close  the 


I  lav  of  the  disra 


patient  w^eighed  five  and  a  half  pounds  more  than  a  week  before  the  begin- 
ning of  the  disease  (Tig.  31).  The  temperature-chart  of  the  case  is,  as  is  so 
frequent  in  the  mildest  cases  of  typhoid  fever,  wholly  uncharacteristic.  The 
temperature,  alternately  remittent  and  intermittent,  but  once  reached  39°  C. 

With  regard  to  the  course  of  the  incompletely  developed,  abbreviated 
cases  in  general,  it  has  been  pointed  out — and  of  this  the  case  last 
related  affords  a  good  illustration — that  many,  in  addition  to  the  brevity, 
are  characterized  besides  by  unusual  mildness  of  the  symptoms,  so  that 
they  well  deserve  the  qualification  "  mildest."  These  cases  set  in  either 
imexpectedly  with  a  chill  or  a  feeling  of  chilliness,  or  after  slight  pro- 
dromes, and  then  the  maximum  temperature  is  reached  either  gradually 
or  more  rapidly,  occasionally  ])efore  the  end  of  twenty-four  hours.  In 
all,  the  general  condition  is  but  slightly  disturbed.     The  patients  are 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  299 

at  most  somewhat  apathetic,  restless  and  sleepless  at  night,  but  almost 
wholly  without  delirium.  The  pulse  remains  good  throughout,  and  is 
often  remarkably  slow.  Complications  and  unusual  localization  of  the 
typhoid  process  are  extremely  rare.  After  the  fever  has  lasted  from  six 
to  ten  days,  the  patients  recover  rapidly  and  completely. 

A  number  of  cases  that  should  likewise  be  included  in  the  category 
of  the  mildest  form  of  typhoid  fever  exhibit  during  the  first  few  days 
severe  but  transitory  general  manifestations,  with  somewhat  higher 
fever,  but  the  course  subsequently  assumes  a  mild  character,  terminating 
in  uncomplicated  convalescence.  We  may  also,  with  a  certain  degree 
of  propriety,  include  in  the  class  of  mild  cases  those  which  exhibit 
relatively  high  remittent  fever,  which  persists  for  days,  but  which  is  not 
accompanied  by  corresponding  acceleration  of  the  pulse-frequency  or  by 
especial  disturbance  in  the  general  condition,  and  in  which  convalescence 
begins  in  the  course  of  six  or  eight  days,  the  fever  subsiding  by  crisis 
or  rapid  lysis.  They  occupy  a  position  midway  between  the  "  typhus 
levis "  and  the  "  typhus  abortivus  "  of  Liebermeister,  constituting  a 
transition  between  these  groups,  and  in  their  typical  form  they  illus- 
trate the  saying  "Parturiunt  montes,  macetur  ridiculus  mus."  Such 
cases  generally  begin  with  abrupt  elevation  of  temperature  following  a 
chill,  and  are  marked  at  times  by  quite  severe  symptoms  of  general 
intoxication  at  the  height  of  the  fever,  which  at  night  may  attain  a 
level  of  40°  C.  or  more;  they  also  occasionally  show  especial  involve- 
ment of  the  internal  viscera,  such  as  particularly  severe  diffuse  bron- 
chitis and  albuminuria  and  nephritis  of  early  onset.  These  cases 
almost  make  the  impression  that  all  the  severe  symptoms  of  typhoid 
fever  were  being  crowded  into  a  short  time ;  and  they  not  rarely  give 
rise  to  anxiety,  which,  however,  is  soon  dissipated  by  a  critical  or  at 
least  rapid  subsidence  of  the  temperature,  often  accompanied  by  sweats. 
Evidence  of  the  fact  that  severe  disturbances  have  taken  place  in  the 
body  even  durmg  the  short  duration  of  the  disease  is  afforded  by  the 
fact  that  convalescence  is  often  disproportionately  protracted,  strength 
is  but  slowly  regained,  and  the  loss  of  weight  is  at  times  very  con- 
siderable (see  the  case  illustrated  by  Fig.  27). 

The  course  of  these  true  abortive  cases  is  generally  as  long  as  that 
of  the  mild  and  very  mild  cases.  Even  more  markedly  than  in  the 
latter,  one  may  note  that  the  incompleteness  in  development  is  at  the 
expense  of  the  initial  stage  and  the  period  of  defervescence,  so  that  the 
duration  of  the  fastigium  with  relatively  high  fever  is  often  rather  pro- 
tracted. With  regard  to  the  course  of  the  fever  during  the  latter 
period,  the  remittent  continued  type  predominates,  but  complete  mter- 


300 


TYl'llnW  FEVER. 


mittence  and  absolute  ^regularity  iu  the  temperature-curve  may  exist 
together  with  alarming  general  manifestations. 

While,  as  has  been  emphasized,  the  general  manifestations  in  the 
mildest  cases  of  typhoid  fever,  as  well  as  those  referable  to  single 
organs,  are  likely  to  be  extremely  mild,  in  abortive  typhoid  fever,  in 
spite  of  the  short  duration,  certain  organs  are  at  times  seriously  affected 
— a  further  evidence  of  the  severity  of  the  infection  under  certain  circum- 
stances. Thus  the  case  illustrated  by  Fig.  27  showed  that  albuminuria 
may  be  present  as  early  as  the  fourth  day  of  the  disease,  although  in 
severe  cases  of  the  ordinary  type  it  is  not  likely  to  appear  before  the 

Day  of  the  disease. 


Fig.  32. 


middle  of  the  second  week.  Still  more  instructive  is  a  case  of  abortive 
or  mild  typhoid  fever  which  was  under  my  observation,  the  onset  of 
which  was  attended  with  nephritis,  and  which  pursued  its  course  amid 
the  clinical  manifestations  of  the  latter  condition,  and  which  therefore 
may  be  appropriately  called  an  example  of  nephrotyphoid. 

A  saleswoman,  twenty  years  old,  was  admitted  for  hemorrhagic  nephritis 
after  she  had  heeii  ill  for  two  days.  The  amount  of  urine  was  considerably 
diminished,  and  the  secretion  was  dark  and  bloody  and  contained  an  abun- 
dance of  albumin,  large  numbers  of  epithelial  cells,  and  hyaline  and  blood- 
casts.     The  temperature  (Fig.  32),  which  was  38.7°  C.  on  the  evening  of 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  301 

the  third  day  of  the  disease,  rose  on  the  following  three  days  to  between 
39.4°  and  39.6°  C.  In  addition  to  this  degree  of  elevation  of  temperature, 
which  was  considerable  for  a  case  of  acute  nephritis,  the  jjalpable  eularge- 
nient  of  the  spleen  that  was  present  on  admission  was  striking.  On  the 
ninth  day  of  the  disease  distinct  roseolte  made  their  appearance  upon  the 
chest  and  abdomen,  with  rather  abundant  new  crops  up  to  the  eleventh 
day.  The  nature  of  the  attack  was  thus  established.  Defervescence  set  in 
between  the  eleventh  and  the  twelfth  day  of  the  disease.  Convalescence 
was  thereafter  uninterrupted.  The  albumin  had  disappeared  from  the  urine 
upon  the  sixteenth  day,  while  blood  and  epithelial  casts  were  no  longer 
demonstrable  after  the  eighth  day. 

With  regard  to  the  individual  symptoms  characteristic  of  typhoid 
fever,  the  occurrence  of  enlargement  of  the  spleen  is  quite  as  frequent 
in  all  abbreviated  mild  or  abortive  cases  as  in  those  that  are  completely 
characteristic.  According  to  my  observations,  the  enlargement  of  the 
spleen  occurs  more  frequently  at  a  comparatively  early  period — in  the 
first  days  of  the  fever  or  even  before  its  commencement — in  the  mild 
and  abortive  cases  than  in  the  completely  characteristic  ones.  It  has 
been  especially  in  these  cases,  which  later  pursued  an  abortive  course, 
that  the  complaint  of  the  patient  of  tenderness  in  the  splenic  region, 
even  before  the  onset  of  fever,  has  led  me  to  examine  the  spleen. 

The  roseolse  seem  to  be,  on  the  whole,  less  profuse  and  less  constant 
in  the  abbreviated  cases  than  is  the  enlargement  of  the  spleen.  In 
some  cases  they  appear  remarkably  early,  during  the  first  few  days  of 
the  fever ;  while  in  others  their  presence  is  synchronous  with  the 
enlargement  of  the  spleen  or  shortly  afterward.  Not  rarely  their 
appearance  is  delayed,  and  sometimes  they  appear  after  the  fever 
has  subsided.  I  have  even  in  a  number  of  instances  observed  the  first 
rQseolse  only  after  defervescence,  on  the  eighth  or  the  nmth  day  of  the 
disease,  therefore  at  the  time  when  they  would  have  appeared  in  ordi- 
nary, completely  developed  cases.  Complete  absence  of  the  roseolse 
seems  to  me  to  be  more  frequent  in  the  abbreviated  cases  than  in 
those  pursuing  a  regular  course — a  circumstance  that  contributes  in  no 
small  degree  to  the  increased  difficulty  in  diagnosis.  Unusual  profusion 
of  the  exanthem  is  rare,  but  the  case  previously  referred  to  (p.  296) 
demonstrates  the  possibility  of  its  occurrence. 

Sudamina  are  comparatively  rare  in  cases  with  relatively  low  tem- 
perature, but  I  have  often  observed  them  during  the  period  of  defers^es- 
cence  in  abortive  cases  with  high  and  long-contiuued  fever.  Meteorism 
is  frequently  absent  in  cases  of  mild  or  very  mild  character,  and  is  gen- 
erally slight  when  it  occurs  in  abortive  t}^hoid  fever.  Characteristic 
diarrhea  appears  to  be  less  common  in  these  than  in  the  well-developed 
cases.     As  has  repeatedly  been  pointed  out,  this  absence  of  diarrhea 


302  TYPHOID  FEVER. 

naturally  does  not  prove  much  with  reference  to  the  degree  of  develop- 
ment of  the  s})ec'iiic  intestinal  lesions.  On  the  contrary,  in  some  cases, 
which  apparently  alforil  no  ground  for  anxiety,  the  most  undesirable 
surprises  are  experienced,  for  instance,  sudden  intestinal  hemorrhage  or 
peritonitis. 

Under  such  circumstances  I  have  seen  peritouitis  occur  in  different 
forms.  In  a  few  cases  in  which,  during  attacks  of  ty})lioi(l  fever  of  mild 
onset,  irritative  symptoms  in  the  right  iliac  fossa  with  ])erity})lilitic  exudate 
appeareil,  the  eourse  was  relatively  favorable.  Cases  of  fatal  perforative 
peritonitis  have  been  mentioned  on  page  226.  Sudden  intestinal  hemorrhage 
also  may  convert  mild,  perhaps  and)ulatory,  cases  into  serious  ones.  I  have 
seen  instances  of  this  kind  in  which  the  occurrence  of  intestinal  hemorrhage 
gave  the  first  suggestion  that  typhoid  fever  should  be  looked  for.  One  of 
my  patients,  a  man  foi'ty  years  old,  was  admitted  on  account  of  sudden, 
severe  bloody  diarrhea,  with  a  diagnosis  of  duodenal  ulceration.  It  was 
stated  that  he  had  been  quite  healthy  before  the  occurrence  of  the  acci- 
dent, and  bad  continued  at  his  work  without  interruption.  A  few  days  fol- 
lowing his  admission,  after  the  bloody  discharges  had  been  replaced  by  thin, 
pea-soup-like  stools,  the  temperature,  which  on  admission  had  been  sub- 
normal, rose  in  the  evening  to  39°  C.  This  was  followed  by  remittent  fever 
of  moderate  severity  for  a  period  of  eight  days,  with  decline  of  the  tempera- 
ture bv  lysis.  The  suspicion  that  the  condition  was  one  of  typhoid  fever  with 
hemorrhage  from  the  bowel  was  completely  verified,  but  only  when,  after  an 
afebrile  interval  of  eleven  days,  a  severe  relapse  of  fifteen  days'  duration 
occurred,  with  enlargement  of  the  spleen,  distinct  roseolte,  and  again  with 
thin  stools.  In  a  second  case  under  my  observation  in  which  the  hem- 
orrhage had  occurred  after  an  indefinite  illness  of  several  days'  duration, 
attended  with  slight  fever,  a  fully  developed  relapse  confirmed  the  suspicion 
of  its  typhoid  origin.  Cases  of  mild  and  abortive  typhoid  fever  with  intes- 
tinal hemorrhage  are  mentioned  also  by  Liebermeister,  who  cites  similar 
observations  by  Louis'  and  Vallin.^ 

Diffuse  bronchitis  is  not  rare  in  cases  of  abortive  typhoid  fever,  as  is 
evident  from  the  clinical  histories  already  detailed,  and  I  consider  it 
one  of  the  most  valuable  diagnostic  symptoms  if  its  onset  can  be  shown 
to  have  occurred  simultaneously  with  the  remaining  symptoms.  Pneu- 
monic complications  have  occurred  in  my  experience  with  extreme  rarity 
in  cases  of  abortive  typhoid  fever.  Complications  and  sequels  localized 
in  other  organs  are  no  less  rare  in  the  abbreviated  forms  of  typhoid 
fever  than  in  the  ordinary  form. 

With  reference  to  convalescence,  it  has  been  stated  that  in  corre- 
spondence with  the  mildness  of  the  symptoms  it  is  frequently  remarkably 
short  and  uncomplicated,  and  attended  with  considerable  increase  in 
weight — often  beyond  the  previous  weight.  The  cases  of  severe  onset 
and  early  high  fever  are,  however,  often  followed  by  quite  a  long  period 

»  Loc.  cit.,  T.  ii.,  p.  332.  ^  Arch.  gen.  de  Med.,  Nov.,  1873. 


VARIATIONS  IN  SYMPTOMS  AND   COURSE.  303 

of  convalescence  with  considerable  emaciation  and  rather  slow  restora- 
tion of  the  previous  body-weight. 

It  is  worthy  of  especial  mention  that  the  mild  and  abortive  cases  are 
followed  by  recrudescences  and  relapses  with  particular  frequency,  pos- 
sibly with  greater  frequency  than  the  severe  cases.  In  addition,  tlie 
secondary  attacks  are  generally  more  intense,  of  longer  duration,  and 
more  characteristic  than  the  prunary  attack.  Thus,  it  is  not  rare  for 
the  nature  of  a  case  to  be  obscure  or  altogether  unrecognized  during  the 
first  febrile  period,  and  not  to  be  viewed  in  its  proper  light  until 
the  occurrence  of  a  relapse,  with  its  characteristic  symptoms,  roseola, 
enlargement  of  the  spleen,  etc.  In  not  a  few  instances  the  attack  is 
not  terminated  with  a  single  relapse.  I  have  observed  two  and  even 
three  relapses  and  recrudescences  following  a  mild  primary  attack. 

With  regard  to  the  total  duration  of  the  imperfectly  developed  cases, 
the  brevity  of  the  attack  is,  as  was  emphasized  at  the  outset,  the  most 
characteristic  feature  of  these  cases.  A  duration  of  the  fever  for  more 
than  ten  or  twelve  days  is  extreme.  Often  enough  it  is  only  from 
three  to  six  days.  When  convalescence  is  rapid  and  uncomplicated, 
not  a  few  cases  terminate  within  three  weeks,  but  even  cases  of  only 
fourteen  days'  duration  or  slightly  more  occur.  On  the  other  hand,  at 
the  beginning  of  even  mild  cases  the  possibility  of  the  course  being 
protracted  or  convalescence  being  prolonged  owing  to  recrudescences  and 
relapses  must  be  kept  in  mind  in  expressing  an  opinion  as  to  the  prob- 
able duration. 

Symptoms  due  to  Typhoid  Toxins. — Although  almost  all 
writers  who  have  studied  the  atypical,  abbreviated  forms  of  typhoid 
fever  have  expressed  an  opinion  as  to  the  conditions  attending  its  devel- 
opment, none  of  the  theories  hitherto  put  forward  appears  to  be  suffi- 
cient. It  is  easy  to  say  that  the  conditions  are  dependent  upon  the 
action  of  attenuated  bacilli,  or  upon  a  quantitatively  slight  mfection 
{"Typhe  en  petite  dose"  of  the  French),  or  upon  slight  susceptibility  of 
the  organism,  or,  on  the  other  hand,  upon  marked  eliminative  capacity 
on  the  part  of  the  body.  Although  these  statements  may  contam  much 
that  is  true,  so  far  as  actual  knowledge  is  concerned,  these  hypotheses 
are  only  formulated  problems.  The  solutions  must  be  gained  step  by 
step  by  means  of  painstaking  experimental  investigation. 

Considering  the  question  from  this  point  of  view,  one  may  go  stiU 
further  with  reference  to  the  production  of  certain  cases,  and  ask — ISIay 
not  all  the  peculiar  symptoms  in  human  beings  be  induced  by  the 
action  of  typhoid  toxins,  just  as  can  be  done  experimentally  in  animals, 
as  has  been  demonstrated  with  certainty  by  Frankel  and  Sunmonds, 


304  TYPHOID  FEVER. 

Kitasato  and  Wassermann,  Sirotinin,  Baumgarteu,  aiul  others?  Un- 
doubtedly abundant  po^^!^ibility  and  opportunity  arc  afforded  for  such 
intoxication.  It  would  be  necessary  to  consider  in  such  cases  especially 
the  accidental  ingestion  of  greatly  infected  articles  of  food  in  which  the 
contained  bacilli,  after  having  greiitly  multiplied,  had  been  destroyed  by 
heating,  cooking,  baking,  and  the  like,  and  their  toxins  alone  remained 
active. 

That  the  human  organism — presupposing  favorable  personal  and 
external  conditions — reacts  to  the  introduction  of  such  poisons  does  not 
appeiu*  to  me  to  be  in  the  slightest  degree  doubtful.  As  a  matter  of 
fact,  I  have  repeatedly  observed  in  the  course  of  house  and  family 
endemics  during  periods  when  typhoid  fever  w^as  severe,  in  addition  to 
characteristic  cases  of  varying  severity,  others  whose  explanation  was  most 
readily  furnished  by  the  assumption  of  the  exclusive  action  of  toxins 
upon  the  organism.  These  were  more  or  less  severe,  at  times  quite  severe, 
cases  which  generally  occurred  in  young  individuals,  servants,  cooks,  etc., 
and  had  a  duration  of  from  twenty-four  to  forty-eight,  and  not  more  than 
seventy-two,  hours.  The  patients  complained  of  severe  headache  and 
vertigo,  shooting  pains  in  the  sacral  region  and  in  the  lower  extremities, 
with  marked  cutaneous  and  muscular  hyperesthesia.  They  were  restless 
and  sleepless,  and  toward  the  evening  and  at  night  even  slightly  stupor- 
ous. Almost  all  the  patients  exhibited  from  the  outset  marked  nausea 
and  vomiting.  In  addition  to  total  anorexia  or  even  disgust  for  all 
food,  they  suffered  from  burning  thirst.  The  tongue  was  heavily  coated 
throughout,  at  times  to  such  a  degree  in  the  course  of  a  few  hours  that 
it  appeared  as  if  boiled. 

At  the  same  time  severe  diarrhea  occurred  in  many  without  the 
characteristic  pea-soup-like  color  of  the  stools.  Quite  exceptionally 
distressing  tenesmus  with  mucous  and  bloody  stools  was  observed — a 
manifestation  that  recalled  forcibly  to  my  mind  certain  lesions  of  the 
large  intestine  induced  exj)erimentally  in  animals  by  means  of  typhoid 
toxins.  In  the  majority  of  cases  there  Avas  slight  meteorism.  I  have 
observed  enlargement  of  the  spleen  in  a  number  of  instances,  but  have 
never  seen  roseolse.  At  times,  in  the  course  of  from  twelve  to  eighteen 
hours  after  the  onset  of  the  disease,  there  was  moderate  albuminuria, 
which  invariably  soon  subsided,  with  a  small  number  of  hyaline  tube- 
casts,  but  without  other  characteristic  morphologic  elements,  and  par- 
ticularly without  blood. 

Generally  the  cases  were  attended  with  fever,  setting  in  with 
repeated  sensations  of  chilliness  or  a  definite  chill,  the  temperature 
reaching  30°  C.  in  the  morning,  and  at  times  40°  C.  or  above  in  the 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  305 

evening.  I  have  not  as  yet  observed  death  as  a  result  of  this  form  of 
the  disease,  although  the  condition  in  some  instances  appeared  quite 
alarming,  and  impressed  even  the  laymen  as  a  state  of  profound 
intoxication.  The  subsidence  of  the  symptoms  occurs  in  the  course  of 
from  twenty-four  to  seventy-two  hours  at  the  latest,  and  is  almost 
always  associated  with  rapid  decline  in  the  temperature,  accompanied  by 
profuse  sweating.  Even  after  the  disappearance  of  all  other  morbid 
symptoms  there  often  remain  unusual  prostration  and  languor,  which 
keep  some  patients  in  bed  or  in  their  rooms  for  more  than  a  week. 
Such  instances  require  only  to  be  mentioned  in  order  to  remind  other 
physicians  of  similar  cases  in  their  own  experience.  For  further  studies 
it  would  certainly  be  worth  while  to  compare  again  the  clinical  picture 
observed  in  human  beings  with  the  results  of  the  experimental  action 
of  toxins  in  animals. 

To  what  extent,  if  at  all,  the  shortest  of  the  atypical  cases  described 
in  the  preceding  section  depend  upon  the  action  of  toxins  alone  or  upon 
a  combination  of  this  with  that  of  attenuated  cultures  ;  whether  certain 
especially  violent  severe  cases  of  short  course  are  possibly  to  be  con- 
sidered as  examples  of  "  toxin-typhoid  fever,"  are  questions  which  must 
for  the  present  remam  undecided.  It  appears  quite  interesting  to  me 
in  this  connection  that  Chantemesse  ^  found,  on  puncture  of  the  spleen 
in  cases  of  abortive  typhoid  fever,  that  the  splenic  juice  was  free  from 
the  bacilli  of  Eberth,  and  he  attempts  to  explain  this  circumstance  hj 
assuming  that  in  these  cases  the  bacilli  penetrate  less  deeply  into  the 
tissues. 

THE  LATENT  VARIETIES. 

Ambulatory  Typhoid  Fever;  Afebrile  Typhoid  Fever 

Among  the  latent  varieties  might  be  mcluded  also  those  cases  m  which 
the  attack  of  typhoid  fever  begins  and  continues  amid  severe  but 
unusual  symptoms,  so  that  at  the  onset,  and  not  rarely  throughout,  its 
nature  may  be  unrecognized — nephrotyphoid,  pneiunotyphoid,  pleuro- 
typhoid,  typhoid  fever  setting  ua  with  menmgitis  or  psychoses.  These 
varieties,  however,  will  be  more  appropriately  considered  at  some  other 
place.  Those  cases  will  be  considered  as  belonging  to  the  latent 
varieties  in  the  strict  sense  of  the  word  that  are  characterized  by  absence 
or  mildness  of  the  fever  or  such  slightness  of  other  symptoms  that  the 
patient  is  not  really  conscious  of  the  existence  of  a  serious  disorder. 

Ambulatory   Typhoid    Fever— The  qualification  ambulatory  was 
introduced  by  Griessinger,   and   is  generally   employed    especiaUy   in. 

1  Traite  de  Med.,  p.  771,  and  Sem.  med..,  Nov.,  1889. 
20 


306  TYPHOID  FEVER. 

Gennany.  In  France,  where  its  existence  is  actually  denied  by  some 
writers  (Brouardel),  the  qualification  latent,  which  in  my  opinion  is  less 
distinctive  (Louis,  Chomel,  and  others),  is  more  commonly  employed. 
The  qualification  ambulatory  applies  naturally  to  the  most  consjjicuous 
feature  of  the  clinical  picture :  the  patients  do  not  go  to  bed,  but  con- 
tinue more  or  less  fidly  in  the  pursuit  of  their  usual  occupations.  This 
presupposes  that  the  symptoms  are  at  the  outset  and  throughout  the 
course  so  slight  that  the  patient  either  does  not  complain  at  all  or 
makes  but  little  of  his  ill-defined  discomfort.  Some  patients,  it  is  true, 
suffer  more ;  they  are  conscious  of  being  ill  and  feverish.  They,  how- 
ever, resist  the  disease,  and  in  this  are  encouraged  by  their  friends, 
since,  as  not  rarely  occurs  under  unfavorable  external  conditions,  they 
are  frequently  considered  as  simulators  or  malingerers. 

The  course  of  events  as  elicited  from  the  complaints  of  the  patient 
or  deteruiiued  subsequently  are  usually  as  follows  :  The  disease  gener- 
ally begins  gradually,  insidiously,  at  times  with  a  feeling  of  chilliness, 
which  may  be  repeated  in  the  further  course  of  the  attack.  The 
patients  complain  of  progressively  increasmg  languor,  and  are  pros- 
trated, especially  toward  evening.  They  tire  at  work,  and  during  the 
day  readily  fall  asleep,  while  during  the  night  they  are  hot,  perspir- 
ing, sleepless,  or  disturbed  by  frightful  dreams.  The  face  becomes 
jjale ;  the  mental  state  is  depressed,  at  times  irritable.  Generally  the 
tongue  is  somewhat  coated,  and  almost  always  the  appetite  is  lost  and 
the  sense  of  thirst  increased.  Irregular  action  of  the  bowels,  with  flatu- 
lence, alternates  with  diarrhea,  or  there  is  persistent  constipation.  Some 
patients  complain  of  slight  anginose  symptoms,  while  others  exhibit 
bronchitic  manifestations  and  believe  themselves  to  be  suffering  fi-om 
a  "  cold  "  or  from  influenza. 

Temperature-observations  are  naturally  made  irregularly,  if  at  all, 
in  private  practice,  in  cases  of  ambulatory  typhoid  fever ;  and  as  the 
patients  are  seldom  sent  to  the  hospitals,  a  thorough  study  is  as  yet 
wanting.  According  to  my  observation,  the  temperature-course  may 
be  of  several  varieties.  Thus,  there  may  be  simple  remittent  fever  at  a 
low  level,  so  that  in  the  morning  the  temperature  rises  little  above  the 
normal,  if  at  all.  Quite  commonly  also  irregular  variations  occur,  with 
a  sudden  elevation  during  the  morning  or  in  the  middle  of  the  day,  as 
a  result  of  excitement,  overexertion,  etc.,  or  without  obvious  cause. 
Other  cases  pursue  an  afebrile  course  throughout,  or  at  least  for  several 
days.  An  intermittent  febrile  course  is  least  common,  in  which  eleva- 
tion of  the  temperature  may  take  place  daily,  with  a  chill  or  with  feel- 
ings of  chilliness.     In   a   number  of  instances   I   have   observed  that 


VABIATIONS  IN  SYMPTOMS  AND  COURSE.  307 

under  such  conditions  this  ascent  takes  place  not  toward  evening,  but 
regularly  at  a  time  when  the  patient  is  most  actively  engaged ;  it  is 
therefore  in  the  nature  of  a  reaction  to  external  influences.  Thus,  I 
recall  the  case  of  a  physician  who  during  an  attack  of  ambulatory 
typhoid  regularly  exhibited  chilliness  with  marked  fever  after  his  con- 
sultation-hour at  about  noon,  while  during  the  remaining  time  the  tem- 
perature was  normal,  however  often  observations  were  made.  Another 
patient-  under  my  care,  an  attorney,  had  his  attacks  of  fever  in  the 
morning  during  the  sessions  of  court.  The  physician  referred  to 
believed  himself  suffering  from  malaria,  until  a  relapse,  with  character- 
istic temperature-curve,  diarrhea,  and  roseolse,  cleared  up  the  nature  of 
the  attack ;  while  in  the  other  patient,  who  voided  remarkably  high- 
colored,  dark,  brownish-red  urine  during  the  febrile  period,  paroxysmal 
hemoglobinuria  was  at  first  suspected. 

The  pulse  appears  in  almost  all  cases  to  be  remarkably  frequent 
from  the  beginning,  relatively  more  so  than  in  typhoid  patients  who 
have  gone  to  bed.  Whether  dicrotism  occurs  or  not,  I  do  not  know. 
In  a  considerable  number  of  patients  the  action  of  the  heart  appears  to 
be  even  more  unstable  than  the  state  of  the  body-temperature,  so  that 
some  complain  only  of  attacks  of  palpitation.  The  physician  previously 
referred  to  had  himself  detected  intermission  of  the  pulse,  and  had 
conceived  all  possible  hypochondriacal  ideas  in  regard  to  it,  although 
no  special  change  in  the  heart  could  subsequently  be  demonstrated. 

Even  at  the  primary  exammation  in  cases  of  ambulatory  typhoid 
fever  distinct  enlargement  of  the  spleen  is  not  rarely  found.  Occasion- 
ally the  patients  themselves  direct  attention  to  this  by  complaints  of 
abnormal  sensations  in  the  left  hypochondrium.  Roseolse  also  are  not 
infrequently  found  on  careful  examination,  although  generally  in  small 
numbers.  I  have  personally  been  able  to  demonstrate  them  in  patients 
who  consulted  me  in  my  office — once,  for  instance,  in  a  young  woman 
from  Russia,  who  had  been  sent  to  Franzensbad  on  account  of  "  chlo- 
rosis with  hysteric  symptoms,"  and  becoming  herself  doubtful,  had  con- 
sulted me  en  route. 

With  regard  to  the  course  and  the  duration  of  ambulatory  t^^phoid 
fever,  naturally  no  definite  statement  can  be  made  for  the  majority  of 
cases.  Undoubtedly  two  principal  varieties  occur  in  this  form  of  the 
disease.  The  one  includes  the  well-developed  cases  of  typhoid  fever 
of  usual  duration.  In  these  the  disease  extends  over  from  four  to  six 
weeks,  when  recovery  occurs.  If  such  developed  cases  unexpectedlv 
terminate  fatally, — as  unfortunately  not  uncommonly  occur.s,  particularly 
from  hemorrhage  and  perforative  peritonitis, — they  often  occasion  sur- 


308  TYPHOID  FEVER. 

prise  at  post-mortem  cxamiuatiou  on  account  of  the  unusual  develop- 
ment and  extent  of  the  intestinal  lesions  and  other  characteristic  visceral 
changes. 

The  second  group  of  cases  more  closely  approximates  the  conditions 
present  in  the  undeveloped,  mild  cases,  and  might  equally  well  have 
been  discussed  in  the  preceding  chapter.  By  reason  of  their  short  dura- 
tion and  the  circumstance  that  the  slight  disturbances  rarely  restrain 
the  patients  in  their  accustomed  occupations,  they  certainly  often  escape 
recognition,  especially  when  they  occur  isolated  and  without  any  dis- 
tinct connection  with  well-developed  cases  of  typhoid  fever.  Not  a 
few  cases  of  "  cold,"  "  angina,"  "  acute  gastro-intestinal  catarrh,"  or 
"  influenza  "  may  belong  in  this  group.  Other  cases  of  the  ambulatory 
type — exactly  as  was  mentioned  as  occurring  in  cases  of  mild  typhoid 
fever — are  recognized  only  when,  after  slight  symptoms  have  been 
present  for  days,  there  occurs  a  recrudescence  or  a  relapse,  accompanied 
by  roseolae,  enlargement  of  the  spleen,  and  characteristic  intestinal 
symptoms.  It  should  be  expressly  emphasized  at  this  place  that  even 
the  apparently  mild,  ambulatory  cases  of  short  duration  may,  though 
apparently  seldom,  reveal  themselves  by  intestinal  hemorrhage  and  peri- 
tonitis, and  terminate  fatally  therefrom. 

With  regard  to  age  and  sex,  I  believe  the  statement  is  justified  that 
ambulatory  typhoid  fever  occurs  more  frequently  in  adults  than  in 
children.  Among  the  former,  in  my  experience,  the  young  and  older 
individuals  seem  to  be  about  equally  predisposed.  I  have  even  observed 
ambulatory  typhoid  fever  in  debilitated,  elderly  individuals.  With 
regard  to  sex,  men  are  distinctly  more  commonly  affected  than  women. 
They  are  more  resistant,  less  sensitive,  and,  among  the  lower  classes, 
often  secure  relief  by  the  use  of  alcohol  from  symptoms  that  would 
cause  others  to  take  to  their  beds. 

Some  persons  with  ambulatory  typhoid  fever  may  perform  surprising  tasks. 
A  salesman  who  had  already  been  ill  between  two  and  three  weeks  had  daily 
continued  at  his  work  without  interruption,  and  had  walked  four  hours  on  the 
day  of  his  admission  to  the  hospital,  the  reason  for  his  coming  having  been  a 
slight  intestinal  hemorrhage  while  going  about.  On  admission,  enlargement 
of  the  spleen,  slight  meteorism,  and  a  profusion  of  roseolse  were  demonstra- 
ble. Another  patient  under  my  care,  a  pilot,  forty-two  years  old,  had  con- 
tinued in  service  uninterruptedly  throughout  the  entire  journey  from  New 
York  to  Hamburg,  although  he  had  for  a  number  of  days  suffered  from 
anorexia,  diarrhea,  occasional  headache,  and  vertigo ;  he  had  even  remained 
almost  constantly  at  his  post  during  the  last  stoi-my  days  in  the  English 
Channel.  On  the  day  of  his  arrival  at  Hamburg  the  sudden  development 
of  symptoms  of  circumscribed  peritonitis  compelled  his  entrance' into  the 
hospital.  On  admission  he  presented  moderate  fever,  but  no  other  than  the 
local  manifestations.     It  was  not  until  after  the  disappearance  of  the  peri- 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  309 

tonitic  symptoms,  twelve  days  after  admission,  that  a  marked  recrudescence, 
lasting  "fourteen  days,  with  high  fever,  enlargement  of  the  spleen,  and 
roseolie,  rendered  certain  our  suspicion  that  the  case  might  be  one  of  ambu- 
latory typhoid. 

Afebrile  Typhoid  Fever. — Although  w^ith  increasing  know^ledge  of 
the  nature  and  manifestations  of  typhoid  fever  some  symptoms  which 
were  earlier  considered  pathognomonic  of  this  condition  were  found  not 
to  be  so,  it  was  nevertheless  believed — and  this  was  still  the  opinion  of 
Griessinger  and  Wunderlich — that  there  could  be  no  typhoid  fever 
without  elevation  of  temperature.  The  modern  conceptions  of  the 
infectious  diseases,  however,  must  of  necessity  have  led  to  the  belief 
that  typhoid  fever  also  might  be  wholly  or  almost  wholly  unattended 
with  elevation  of  temperature,  just  as  occurs  in  other  infectious  diseases, 
as,  for  instance,  scarlet  fever,  measles,  and  variola. 

Every  experienced  physician — the  family  physician  more  frequently 
than  the  hospital  physician — will  be  able  to  recall  that  during  the 
endemic  prevalence  of  typhoid  fever  there  occurred  under  the  same 
roof,  and  amid  the  same  general  conditions,  side  by  side  with  well-char- 
acterized eases  of  the  disease,  others  in  which  individuals  suffered  for  a 
considerable  time  with  marked  languor  and  malaise,  with  headache  and 
vertigo,  irregularity  in  the  action  of  the  bowels,  diarrhea,  or  obstinate 
constipation  with  flatulence,  and  were  compelled  to  remain  in  bed  and 
in  their  room,  and  recovered  but  slowly,  but  in  which,  during  the  entire 
attack,  there  was  no  fever.  In  some  of  these  patients  examination  fails 
to  disclose  any  special  organic  change  throughout  the  entire  course  of 
the  disease.  Loss  of  weight  of  from  8  to  10  pounds  in  the  course 
of  two  weeks,  however,-  indicates  emphatically  that  some  serious  con- 
dition must  have  been  present.  One  cannot  relieve  himself  of  the 
impression  that  the  patient,  who,  in  marked  contrast  with  the  negative 
organic  changes,  has  been  so  greatly  reduced  in  w^eight,  must  have  been 
under  the  influence  of  some  infectious  process  whose  nature,  in  view  of 
the  coincidence  with  pronounced  cases  of  typhoid  fever,  can  scarcely  be 
doubted.  In  other  cases  one  need  not  make  a  diagnosis  by  exclusion. 
There  may  be  present  bronchitic  symptoms,  meteorism,  characteristic 
diarrhea,  isolated  roseolse,  or,  what  is  not  rare  and  is  especially  impor- 
tant, recent  enlargement  of  the  spleen. 

The  frequency  of  such  afebrile  cases  is,  in  view  of  the  uncertainty 
and  variability  of  their  symptomatology,  naturally  difficult  of  estimation. 
Probably  it  is  variable  during  different  epidemics.  AYhether  a  certain 
age  or  sex  especially  predisposes  to  the  condition  is  not  known  to  me 
from  personal  experience,  and,  so  far  as  I  know,  the  question  has  not 


310  TYPHOID  FEVER. 

been  considered  by  other  writers.  The  differentiation  of  the  cases  in 
question  from  supertieially  similar,  afebrile  morbid  conditions  particu- 
larly simple  gastro-intestinal  catarrh,  will,  in  the  future,  by  means  of 
the  Gruber-AVidal  rciiction,  be  rendered  more  certain  than  has  been 
possible  in  the  past.  Probably,  also,  bacteriologic  examination  of  the 
blood,  the  urine,  and  the  stools  will  lead  to  more  definite  results.  It 
would  naturally  be  artificial  to  separate  the  afebrile  cases  of  tyi)hoid 
fever  into  a  rigidly  distinct  group.  They  gradually  pass  over  into  those 
cases  in  which,  during  a  long  afebrile  course,  only  moderate  elevation 
of  temperature  occurs  temporarily  or  for  days.  Afebrile  typhoid  fever 
certainly  contributes  its  contingent  of  cases  to  the  ambulatory  form. 

I  can  personally  give  no  statistical  data  with  reference  to  the  afebrile 
form  of  typhoid  fever,  although  I  have  seen  a  considerahle  nuniher  of  such 
cases.  Most  valuable  contributions,  however,  have  been  made  by  Lieber- 
meister/  who,  agreeing  with  the  practitioners  of  Basle  as  to  diagnosis, 
observed  many  cases  of  afebrile  typhoid  fever.  He  noted  in  1869,  in  addi- 
tion to  206  cases  of  more  or  less  well-developed  typhoid  fever,  29  of  febrile 
and  139  of  afebrile  abdominal  catarrh  ;  in  1870,  26  cases  of  febrile  and  11 
cases  of  afebrile  abdominal  catarrh,  in  addition  to  161  cases  of  marked 
typhoid  fever.  The  statement  of  Liebermeister  is  also  interesting  in  this 
connection,  that  in  Basle  at  that  time  individuals  who  died  of  other  diseases 
or  as  a  result  of  accident  frequently  exhibited  after  death  the  unexpected 
condition  of  slight  swelling  of  Beyer's  patches. 

An  instructive  case  of  afebrile  typhoid  fever  under  my  observation  in 
which  a  post-mortem  examination  was  made  may  be  reported.  It  occurred 
in  a  laborer,  eighteen  years  old,  who  had  been  in  the  hospital  for  two  weeks 
on  account  of  "intestinal  catarrh,"  and  whose  temperature,  taken  three  times 
daily,  was  found  to  be  completely  normal,  with  the  exception  of  one  even- 
in(r,'when,  after  a  visit  which  disturbed  him  considerably,  it  rose  to  38.2°  C. 
He  exhibited  also  no  especial  local  symptoms.  He  was  only  remarkably 
languid,  entirely  without  aj)petite,  prostrated,  and  was  unwilling  to  get  out 
of  bed.  On  the  fifteenth  day  of  the  disease,  quite  without  provocation, 
without  elevation  of  temperature,  symptoms  of  mental  disturbance  appeared, 
with  hallucinations  and  delusions  of  fear.  In  an  unguarded  moment  the 
patient  sprang  from  a  window,  and  died  instantly  in  consequence  of  fracture 
of  the  base  of  the  skull.  The  autopsy  disclosed  a  recent  enlargement  of 
the  spleen  of  moderate  degree,  hyperemia,  and  firm  medullary  swelling  of 
Beyer's  patches  in  the  lower  portion  of  the  ileum,  almost  down  to  the  valve, 
and  upon  one  of  these  a  still  adherent  central  slough,  perhaps  half  an 
inch  in  diameter.  This  observation  was  made  before  the  discovery  of  the 
typhoid-bacillus,  but  the  diagnosis  may  nevertheless  be  considered  as  defi- 
nitely established. 

While  a  number  of  cases  of  afebrile  typhoid  fever  may,  by  reason 
of  their  atypical  and  mild  course,  be  included  among  the  mild  and  the 
mildest  variety,  others,  fortunately  the  great  minority,  belong  to  the 
severe  form,  even  that  with  a  fatal  termination.     The  credit  is  due 

1  Loc.  cit,  3.  Aufl.,  S.  174,  175. 


VARIATIONS  IN  SYMPTOMS  AND   COURSE.  311 

especially  to  Strube  ^  and  Friintzel  ^  for  having  directed  particular 
attention  to  this  subject.  My  own  experiences  are  entirely  in  accord 
with  those  of  the  observers  named.  I  can  confirm  the  statement  that 
severe  fatal  cases  of  typhoid  fever  in  elderly,  decrepit  persons,  or  in 
those  debilitated  by  overexertion,  alcoholism,  or  chronic  disease,  may 
be  entirely  unattended  with  fever,  or  may  even  be  accompanied  by  a 
subnormal  temperature. 

SEVERE   AND   MODERATE    CASES    OF   ATYPICAL   COURSE   AND 
SYMPTOMATOLOGY. 

In  this  section  will  be  discussed  the  essential  facts  with  regard  to 
such  cases  of  typhoid  fever  as  present  deviations  from  the  usual  symp- 
tomatology of  the  disease  by  reason  of  peculiarities  in  their  course  in 
general,  or  on  account  of  the  predominant  role  played  by  certain 
systems  or  individual  organs.  The  literature  of  different  periods  and 
countries  exhibits  the  greatest  variation  in  this  connection.  While 
in  earlier  times  especial  weight  was  attached  to  the  variable  general 
picture  of  typhoid  fever,  and  accordingly,  as  is  thought  to-day,  the  dis- 
ease was  far  too  schematically  divided  into  a  mass  of  different  forms, 
modern  conceptions  keep  in  mind  rather  the  distinctive  predominance 
of  certain  organic  lesions,  so  that  the  French  literature  especially  is 
thus  rich  in  varieties  established  on  this  basis. 

The  Varieties  with  Atypical  General  Characteristics.— 
These  may  at  the  present  day  be  disposed  of  in  a  comparatively  small 
amount  of  space.  It  is  scarcely  worth  while  to  repeat  all  the  desig- 
nations that  have  arisen  and  have  been  employed  in  the  progress  of  time. 
We  have  previously  mentioned  the  so-called  gastric  and  the  mucous 
fever  {Forme  mueuese  of  the  French),  and  have  pointed  out  that, 
according  to  the  suggestion  of  Griessinger,  these  names  had  better  be 
wholly  abandoned  at  the  present  day,  and  be  replaced  by  those  of  mild 
and  moderately  severe  typhoid  fever. 

Not  much  more  can  be  said  of  the  designations  gastric-bilious  fever 
or  bilious  fever,  which  were  formerly  frequently  considered  as  the  third 
variety  of  the  "abdominal  forms."  Under  these  designations  were 
included  those  cases  of  typhoid  fever  in  which,  usually  in  conjunction 
with  a  moderately  severe  or  a  severe  course,  gastric  disturbances,  a 
bitter  taste,  Avith  a  heavily  coated  tongue,  obstinate  nausea,  and  the 
vomiting  of  bilious  fluid,  with  severe  pain  in  the  epigastrium,  pre- 
dominated from  the  beginning.  Some  writers  mentioned  in  this  connec- 
tion the  frequent  association  of  jaundice.     These  cases  especially,  on 

1  Berlin,  klin.   Woch.,  1871,  No.  30.  «  Zeit  f.  klin.  Med.,  Bd.  ii. 


312  TYPHOID  FEVER. 

account  of  the  well-kno\vii  great  rarity  of  jaundice  in  cases  of  typhoid 
fever,  are  to  be  viewed  with  particuhir  aire.  A  considerabk>  number 
of  them  are  not  to  be  attributed  to  infection  with  the  bacilhis  of 
Eberth,  but  from  the  etiologic  standpoint  they  are  rather  to  be  grouped 
with  other  morbid  conditions,  among  which  septic  processes  and  Weil's 
disease  are  probably-  the  most  importimt. 

Reference  is  very  frequently  made  in  earlier  writings  to  versatile 
nervous  fever  and  to  stupid  nervous  fever.  These  were  long  undis- 
puted as  special  varieties.  As  a  matter  of  fact,  cases  are  frequently 
observed  in  which  the  special  symptoms  indicated  by  these  names  so 
predominate  that  the  names  may  be  retained  as  short  and  appropriate. 
It  should  not,  however,  be  overlooked  that  the  differences  indicated  by 
these  names  are  not  essential,  but  rather  superficial,  and  in  large  part 
individual,  and  that,  besides,  the  great  diversity  of  mixed  and  tran- 
sitional forms  demonstrates  how  little  importance  can  be  attached  to  any 
such  strict  systematic  differentiation. 

The  designation  versatile  nervous  fever  is  applied  to  cases  in  which 
symptoms  of  nervous  excitement  predominate  at  the  height  of  the 
disease,  at  times  also  throughout  the  entire  febrile  period  :  Great  rest- 
lessness, with  marked  motor  and  sensory  irritability,  delirium,  appear- 
ing early,  persisting  into  the  day,  with  vivid,  generally  frightful,  illu- 
sions and  hallucinations,  even  crying  and  shouting,  with  a  constant 
tendency  to  get  out  of  bed,  and  occasionally  attempts  at  flight.  Tremor, 
floctitation,  and  subsultus  tendinum,  even  convulsions,  in  children  and 
irritable  adults  complete  the  clinical  picture,  which  is  most  alarming  to 
the  friends. 

In  contradistinction  to  this  condition,  the  cases  mcluded  under  the 
designation  stupid  nervous  fever  justify  that  name  by  reason  of  the 
depression  w^hich  characterizes  their  course  and  symptoms.  From  the 
outset,  or  at  least  during  the  fastigium,  the  patients  are  greatly  depressed 
physically  and  mentally,  dull,  unresponsive  to  stimulation,  and  without 
will-power.  Sleepless,  wdth  eyes  open  or  half-open,  they  preserve  a 
relaxed  dorsal  decubitus  in  bed,  with  a  constant  tendency  to  slip  down- 
ward. Without  being  entirely  unconscious,  often  being  but  slightly 
stuporous,  they  are  indifferent  both  to  mdividuals  and  to  events  going 
on  about  them.  They  ask  for  neither  food  nor  drink,  but  swallow 
badly  and  slowdy  that  which  is  offered  them,  or  permit  it  to  flow  again 
from  the  mouth.  Not  rarely,  especially  in  young  women  with  a  ner- 
vous predisposition,  the  condition  of  stupor  becomes  increased  to  the 
development  of  symptoms  of  catalepsy.  I  have  more  than  once  been 
able  to  demonstrate  cataleptic  rigidity  with  plastic  flexibility  in  indi- 


VARIATIONS  IN  SYMPTOMS  AND   COURSE.  313 

viduals  who  were  considered  by  their  attendants  as  completely  stupor- 
ous, and  even  in  whom  the  typhoid  fever  was  tliought  to  be  complicated 
by  meningitis. 

The  form  of  stupid  nervous  fever  just  outlined  is  approximately 
identical  with  the  variety  of  typhoid  fever  described  by  the  French 
and  English  as  the  adynamic  form ;  while  they  employ  instead  of  versa- 
tile nervous  fever  the  expression  ataxic  or  irritative  typhoid  fever.  It 
has  been  mentioned  that  transitions  between  these  forms  may  occur  and 
various  clinical  pictures  be  produced.  The  French  literature  gives 
expression  to  this  with  its  ataxo-adynamic  variety,  in  which  the  symp- 
toms of  excitement  and  depression  may  be  present  m  varying  degrees 
simultaneously  or  successively.  The  ataxo-adynamic  variety  also 
resembles  that  designated  the  hyperpyretic  variety,  which  is  charac- 
terized by  the  fact  that  after  the  disease  has  pursued  a  relatively  short 
and  severe  course,  with  depression  and  irritative  symptoms  side  by  side, 
the  fever,  which  from  the  beginning  was  considerable,  rapidly  rises  to 
an  excessive  height,  when  the  majority  of  patients  succumb.  Cases  of 
this  kind,  pursuing  an  especially  severe  course,  closely  resemble,  in  turn, 
the  clinical  picture  of  the  fulminant  variety  previously  described. 

It  is  not  clear  what  cases  earlier  prominent  physicians  (Murchison, 
Trousseau)  included  under  the  designation  of  the  inflanmiatory  variety. 
They  appear  thereby  to  aim  at  the  description  less  of  a  special  variation 
in  the  general  course  rather  than  to  include  under  this  term  such  cases 
of  typhoid  fever  as  are  attended,  especially  at  the  beginning,  with 
severe  fever,  a  tense,  full,  unusually  frequent  pulse,  a  hot,  dry  skin,  an 
intensely  reddened,  swollen  face,  with  injection  of  the  conjunctivae,  a 
burning  thirst,  and  great  dryness  of  the  mouth,  tongue,  and  lips. 

While  the  consideration  of  the  varieties  just  described  was  intended 
to  make  clear  the  differences  between  the  past  and  the  present  methods 
of  classification  of  the  different  forms  of  typhoid,  one  of  these  varieties 
may  now  be  referred  to,  which  even  yet  appropriately  occupies  a  dis- 
tinct position.  This  is  the  so-called  hemorrhagic  typhoid  fever 
(hemorrhagic  putrid  fever  of  Trousseau),  that  variety  that  is  so  strik- 
ingly and  alarmingly  characterized  by  hemorrhages  in  all  possible  por- 
tions of  the  body.  In  a  number  of  rare  cases  it  constitutes  a  form  of 
termination  of  the  fulminant  variety,  while  in  other  cases  it  makes  its 
impress  upon  the  disease  at  the  height,  or  may  even  occur  in  the  later 
stages  of  cases,  which  at  first  exhibited  an  entirely  typical  course,  or 
which  had  even  pursued  a-  protracted  course  (AYagner,^  Gerhardt"). 
This  dangerous  tendency  may  be  first  manifested  during  a  relapse,  and 

1  Deutsch.  Arch.  f.  klin.  Med..,  Bd.  xxxii.,  xxxvii.         ^  Zeit.  f.  klin.  Med.,  Bd.  x. 


314  TYPHOID  FEVER. 

this,  so  far  as  I  know,  was  first  pointed  out  by  Gerliardt  and  myself  on 

the  basis  of  personal  experience. 

Such  au  instance  has  occurred  at  the  Johus  Hopkins  Hospital,  aud  was 
reported  by  Hamburger.  In  this  case  the  hemorrhages  first  appeared  on  the 
fourteenth  day  of  a  relapse,  the  original  attack  having  been  of  moderate 
severity.  There  was  quite  profuse  bleeding  from  the  gums,  and  numerous 
petechitv  and  a  few'  larger  purpuric  spots  were  scattered  over  the  body. 
Notwithstanding  this  complication,  the  patient  made  a  complete  recovery. 

The  first  hemorrhages  appear  to  take  place  generally  from  the  nose. 
Immediately  thereafter,  at  times  simultaneously,  hemorrhages  occur 
from  the  discolored,  spongy  gums.  Then  petechia?  appear  upon  the 
skin  of  the  trunk  and  the  extremities,  scattered  between  the  roseolae, 
which  occasionally  do  not  become  hemorrhagic  or  become  only  slightly 
so.  In  especially  malignant  cases  profound  extravasations  of  blood 
into  the  subcutaneous  connective  tissue,  even  beneath  the  scalp,  may 
occur  (E.  Wagner).  A  considerable  number  of  these  patients  are, 
besides,  seized  with  meningeal  and  cerebral  hemorrhage.  Even  more 
frequently,  indeed  in  the  overwhelming  majority  of  all  cases,  intestinal 
hemorrhage  occurs ;  at  times  being  in  such  abundance  and  occurring 
with  such  frequent  repetition  that  it  may  be  considered  the  direct  cause 
of  death.  In  one  case,  which  terminated  fiitally  as  early  as  the  sixth 
day,  in  the  course  of  a  profuse  hemorrhage  from  the  bowel,  I  found,  as 
the  anatomic  basis  for  the  latter,  that  the  Peyer's  patches  in  the  loM^er 
portion  of  the  ileum  were  exceedingly  spongy,  friable,  and  infiltrated 
with  reddish-black  blood. 

Not  quite  so  common  as  the  forms  of  hemorrhage  mentioned  is  that 
from  the  urinaiy  tract  and  the  genitalia.  Pregnant  Avomen  seized  with 
the  hemorrhagic  variety  of  typhoid  fever  invariably  abort,  and  then  die  as 
a  result  of  uncontrollable  uterine  hemorrhage.  Hemoptysis  appears  to 
be  the  least  constant  form  of  hemorrhage,  and  when  it  occurs,  it  may 
be  attributed  either  to  infarction  or  simply  to  bleeding  from  the  bron- 
chial, tracheal,  and  laryngeal  mucous  membrane.  In  the  further  course 
of  the  disease  gangrenous  processes  may  be  added  to  the  hemorrhages  : 
Ulcerative  destruction  of  the  gums  and  other  parts  of  the  buccal  mucous 
membrane,  pulmonary  gangrene,  generally,  it  is  true,  in  conjunction  with 
infarction,  aud  pseudodij^htheric  lesions  of  the  uterine  and  vesical  mucous 
membrane. 

With  regard  to  the  nature  and  the  mode  of  origin  of  this  extremely 
malignant  variety,  which  is  fortunately  rare,  nothing  is  as  yet  known. 
If  the  modern  clinician  sneers  at  the  expression  "  dissolution  of  the 
blood,"  employed  by  his  predecessors,  he  should  bear  in  mind  that  he 
has  not  as  yet  provided  a  better  substitute.     At  present  we  do  not 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  315 

know  whether  special  characteristics  and  mode  of  action  of  the  typhoid- 
bacillus  or  whether  certain  conditions  of  the  body  or  the  effects  of 
certain  complications  play  the  most  important  roLe  in  this  connection. 
Earlier  writers  (Trousseau)  claimed  to  have  established  that  in  the 
cases  in  question  there  occurred  a  special  alteration  in  the  blood,  char- 
acterized by  a  remarkably  dark  color  and  deficient  coagulability.  I 
have  personally,  in  the  examination  of  one  case  during  life,  not  been 
able  to  demonstrate  either  these  macroscopic  peculiarities  or  noteworthy 
histologic  changes  in  the  blood.  In  the  case  above  mentioned  as  occur- 
ring at  the  Johns  Hopkins  Hospital,  however,  the  coagulation-time  of 
the  blood,  during  the  periods  when  hemorrhages  were  occurring,  was 
increased  to  ten  minutes,  but  during  convalescence  it  again  became 
reduced  to  four  minutes.  It  should  especially  be  emphasized,  however, 
that  neither  in  any  of  my  cases  nor,  so  far  as  I  can  learn,  in  the  litera- 
ture, has  hemoglobinemia  with  hemoglobinuria  been  observed.  Careful 
examination  of  the  blood-vessels,  particularly  the  capillaries,  which 
possibly  may  show  alterations  of  more  importance  than  changes  in  the 
blood  itself,  has  yet  to  be  made. 

With  regard  to  the  general  etiologic  conditions  in  the  cases  in  ques- 
tion, childhood,  as  well  as  youth  and  adolescence,  appears  to  be  more 
predisposed  than  the  later  periods  of  life.  Of  6  cases  under  my  own 
observation,  3  occurred  in  childhood.  The  oldest  of  my  patients  was 
thirty-six  years  of  age.  Wagner  and  Gerhardt  also  emphasize  the  pre- 
disposition exhibited  by  children.  The  constitution  and  the  mode  of  life 
apparently  do  not  play  the  role  that  might  a  priori  be  attributed  to 
them.  Gerhardt  and  Griessinger  include  scorbutic  states,  deficient  nour- 
ishment, and  living  in  overcrowded  rooms  among  the  contributory 
causes.  In  my  cases,  however,  nothing  of  this  character  appeared  m 
the  histories.  Of  great  importance,  however,  appears  to  me  to  be 
previous  alcoholic  excess.  Of  my  3  adult  patients,  2  were  notorious 
drunkards. 

With  regard  to  the  frequency  of  occurrence  of  the  hemorrhagic 
variety,  it  may  be  repeated  that  I  have  personally  observed  only  6 
definite  cases.  Liebermeister  noted  but  3  among  1900  cases  of  t^^jhoid 
fever  m  the  epidemic  at  Basle;  and  Weil  but  1  among  150.  Among 
829  cases  at  the  Johns  Hopkins  Hospital,  only  1  case,  that  above  men- 
tioned, occurred.  Slightly  marked,  mild  hemorrhagic  cases,  however, 
appear  to  be  not  at  all  rare.  Thus,  in  persons  greatly  exhausted  in  the 
sequence  of  protracted,  severe  attacks  of  typhoid  fever,  or  m  those  with 
special  predisposition,  as  in  abnormally  obese  individuals,  women  and 
children,  and  especially  in  beer-drmkers,  there  is  not  rarely  observed  at 


316  TYPHOID  FEVER. 

a  late  stage  of  the  disease  a  marketl  tendency  to  hemorrhage  from  the 
nose,  the  gums,  the  corners  of  the  mouth,  and  fissures  of  the  lips. 
Such  individuals'  exhibit  a  tendency  to  extensive  hemorrhages  into  the 
skin,  the  subcutaneous  connective  tissue,  and  even  into  the  muscles,  as  a 
result  of  the  slightest  traumatic  influences — such  as  the  pressure  of  the 
nurse's  hand  in  movmg  him,  or  of  the  pressure  of  articles  of  clothing 
or  of  the  sheet. 

The  prognosis  in  the  well-marked  hemorrhagic  variety  is  in  general 
the  more  unfavorable  the  earlier  the  hemorrhages  appear  and  the  more 
extensive  they  are.  All  my  (3  cases  terminated  fatally.  A\"agncr  lost 
but  two-thirds  of  his  patients.  The  prognosis  in  the  slightly  marked 
cases  depends  upou  the  other  associated  conditions. 

TYPHOID  FEVER  IN  WHICH  SYMPTOMS  REFERABLE  TO  CERTAIN 
ORGANS  OR  SYSTEMS  PREDOMINATE. 

The  majority  of  the  cases  to  be  considered  in  this  section  have 
alreadv  been  referred  to  in  connection  with  the  analysis  of  the  indi- 
vidual svmptoms.  It  will  be  useful,  however,  particularly  with  regard 
to  the  thagnosis,  to  review  these  clinical  pictures,  and  to  complete  the 
detailed  description. 

Typhoid  Fever  in  which  Symptoms  Referable  to  the 
Central  Nervous  System  Predominate. — Cerebral,  spinal,  and 
cerebrospinal  varieties  may  be  distinguished.  These  have  previously 
been  fully  considered,  so  that  at  this  place  it  will  suffice  to  refer  again 
only  to  the  cases  that  set  in  with  severe  cerebrospinal  symptoms  and  are 
even  characterized  by  a  predominance  of  these  (meningotyphoid),  and 
to  those  in  which  a  complex  of  severe  spinal  symptoms  resembling  acute 
(Landiy's)  ascending  paralysis  obscure  the  picture  of  typhoid  fever 
wholly  beyond  recognition  (Leudet,  Curschmann). 

Of  the  so-called  cerebral  variety,  only  those  cases  will  again  be 
referred  to  that  are  quite  early  associated  with  severe  mental  disturb- 
ances. The  greatest  diagnostic  difficulty  may  attend  those  cases, 
which  are  rare,  it  is  true,  in  which  the  attack  of  typhoid  fever  sets  in 
with  the  symptoms  of  a  psychosis,  and  the  characteristic  manifestations 
of  the  underlying  disease — the  roseolse,  enlargement  of  the  spleen,  and 
diarrhea — do  not  appear  for  days  and  even  for  a  week  after  the  onset. 
It  is  a  matter  of  expediency  to  specify  such  cases  with  the  designation 
cerebral  typhoid. 

Among  the  disorders  of  the  respiratory  organs  that  at  times 
give  an  unusual  character  to  the  course  of  typhoid  fever,  those  of  the 
larynx,  the  lungs,  and  the  pleura  are  the  most  important.    Among  these, 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  317 

those  of  the  larynx  arc  the  rarest  and  the  least  conspicuous.  Cas&s  in 
which  the  entire  clinical  picture  is  dominated  by  the  early  onset  and 
unusual  development  of"  the  typhoid  lesions  of  the  larynx  are  extremely 
rare,  and  the  designation  luryngotyphoid  is  artificial  and  superfluous. 

Of  far  more  significance  are  the  terms  pneumotyphoid  and  jdeuro- 
typhoid.  For  the  justificati<Mi  of  the  designation  pneumotyphoid  Ger- 
hardt,  Potain,  Lepine,  E.  Wagner,  and  recently  Eggert '  have  furnished 
abundant  evidence.  This  condition  is  observed  in  those  cases  of  typhoid 
fever  in  which  symptoms  of  pneumonia  appear  during  the  first  days, 
so  that  the  first  week  is  either  dominated  entirely  by  a  typical  clinical 
picture  of  inflammation  of  the  lung,  or  the  latter  is  attended  with  other 
symptoms  unusual  to  it,  but  which  are  for  a  time  of  undetermined 
significance.  Such  cases  may,  as  has  been  pointed  out,  be  wholly 
unrecognized  at  first,  and  be  correctly  interpreted  only  toward  the  end 
of  the  first  or  even  in  the  beginning  of  the  second  week  of  the  disease, 
when  the  pneumonic  symptoms  recede  and  those  characteristic  of  typhoid 
fever  come  more  into  the  foreground.  Undoubtedly,  the  majority  of 
such  cases  are  to  be  considered  as  due  to  a  mixed  infection.  Among 
the  associated  organisms,  probably  the  diplococcus  of  Frankel-Weichsel- 
baum  occurs  the  most  frequently.  The  cases  are  likely,  just  as  those 
of  genuine  fibrinous  pneumonia,  to  begin  with  a  chill,  with  subsequent 
marked  elevation  of  temperature,  and  to  be  followed  by  the  rapid 
development  of  dense  lobar,  generally  unilateral,  infiltration  of  the 
lungs,  often  with  characteristic  rusty  sputum.  It  is  possible,  however, 
that  the  typhoid-bacillus  may  also  independently  cause  inflammatory 
alterations  in  the  lungs  (as  claimed  by  Lupine,  Chantemesse  and  Widal), 
and  such  cases  would,  as  has  been  pointed  out,  be  examples  of  pneu- 
motyphoid in  the  strictest  sense  of  the  term.  Further  work  is  needed, 
however,  before  it  can  be  considered  as  established  that  such  cases  ever 
occur  (see  page  116).  It  has  been  claimed  that  such  cases  are  charac- 
terized by  frequent  absence  of  the  initial  chill,  by  delayed  involution 
and  absence  of  the  characteristic  rusty  sputum,  and  by  less  rapid 
ascent  of  the  temperature-curve  and  less  dense  infiltration  of  the  lung 
than  occurs  in  the  cases  due  to  the  pneumococcus.  It  is  maintained  by 
some  that  in  such  cases  the  intestinal  symptoms  are  frequently  but 
slightly  marked,  if  at  all,  and  the  development  of  roseolse  is  altogether 
wanting.  Our  experiences  in  this  connection  appear  to  me  to  be  too 
small  as  yet  to  justify  such  general  statements. 

As  an  instance  of  pneumotyphoid  I  may  cite  the  case  of  a  man,  twenty- 
eight  years  old,  in  whom  a  moderate  grade  of  infiltration  of  the  lower  lobe 

^  hiaiig.  Diss.,  Erlangen,  1888. 


318  TYPHOID  FEVER. 

of  the  left  luug,  associated  with  chilliness  and  a  step-like  elevation  of  temper- 
ature, oct'urred.  Associated  with  this  there  were  marked  dryness  of  the 
tuiiuue,  palpable  eularyemeut  of  the  spleen,  and  slight  nieteorism,  but  no 
diarrliea  or  roseoke.  At  the  end  of  the  third  week  of  the  disease,  after  the 
pueunionic  consolidation  had  existed  for  two  weeks,  the  temperature  fell  to 
normal.  Sixteen  days  later  there  developed  the  symptoms  of  a  ty])hoid 
relapse,  with  a  characteristic  febrile  course  of  three  weeks,  with  renewed 
enlar<iement  of  the  spleen,  copious  and  frequent  pea-sonp-like  stools,  and  a 
well-deyeloped  roseolous  exanthem  on  the  trunk  and  the  upper  portions  of 
the  extremities. 

The  course  of  pneumotyphoid  appears  to  be  in  general  not  so  severe 
as  ^youl(l  a  priori  be  expected,  Gerhardt  early  emphasized  this.  In 
one  of  my  cases  death  occurred  from  pulmonary  gangrene.  This  case 
was  not  examined  bacteriologically.  In  another,  due  to  the  Friinkel- 
A\\'ichselbaiim  diplococcus,  empyema  developed,  but  the  case  finally 
terminated  in  recovery.  Although  the  variety  known  as  pneumo- 
typhoid is,  on  the  ^vhole,  rare,  it  does,  nevertheless,  at  some  time  and 
during  certain  epidemics  appear  to  be  more  frequent  (Gerhardt,  E. 
Wagner).  I  have  ]>ersonally  observed  2  cases  of  pneumotyphoid  at 
Berlin  and  1  at  Hamburg  at  times  when  genuine  fibrinous  pneumonia 
prevailed. 

Pleurotyphoid. — Just  as  during  the  course  of  typhoid  fever, 
pleurisy  occurs  much  less  frequently  than  pneumonia,  so  also  does  the 
symptom-complex  that  may  be  designated  pleurotyphoid  appear  to  be 
still  less  frequent  than  pneumotyphoid.  Nevertheless,  experienced 
clinicians  will  be  able  to  recall  cases  in  which  symptoms  of  pleiu^isy 
developed,  generally  associated  with  chilliness  and  subsequent,  more  or 
less  marked,  remittent  continued  fever.  These  cases  were  then  at  first 
considered  as  of  independent,  so-called  rheumatic,  or  of  other  etiologic 
origin,  until  headache,  progressive  stupor,  enlargement  of  the  spleen, 
diarrhea,  and  meteorism,  as  well  as  roseolse,  established  the  existence  of 
an  attack  of  typhoid  fever  presenting  itself  in  this  j)eculiar  and  rare 
manner. 

I  have  personally  observed  4  cases  of  this  character.  In  3  copious 
effusions  developed  rapidly,  being  in  2  of  a  purely  serous  character,  while 
in  1  it  was  serohemorrhagic.  The  fourth  case  was  unattended  with  effu- 
sion. I  shall  briefly  sketch  this  last  case  and  one  of  the  cases  with  efiusion. 
I  saw  the  case  without  effusion  in  the  year  1886,  during  the  typhoid  epidemic 
in  Hamburg.  It  occurred  in  an  assessor,  thirty-one  years  old,  who,  after 
haying  previously  been  entirely  well,  was  seized  during  a  session  with  chilli- 
ness and  severe  pain  in  the  right  side.  Two  days  later  the  patient  showed, 
in  addition  to  the  symptoms  of  slight  diffuse  bronchitis,  extensive  pleuritic 
friction  over  the  lower  lobe  of  the  right  lung.  In  view  of  the  moderate 
elevation  of  temperature,  the  occurrence  of  considerable  stupor,  dryness  of 
the  tongue,  and  a  large,  palpable  splenic  tumor  was  striking.     On  the  fifth 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  319 

day  following  (seventh  day  of  the  disease)  distinct  roseohe  made  their 
appearance  upon  the  abdomen,  chest,  and  back.  (Jonsideriiig  the  tem]jer- 
ature-course  and  the  remaining  symptoms,  there  was  now  no  further  doubt 
that  the  case  was  one  of  typhoid  fever  whose  first  marked  symptoms  were 
referable  to  the  pleura.  The  course  of  the  attack  was  f[ivoral)]e.  The 
patient  was  free  from  fever  after  the  lapse  of  four  weeks,  and  he  recovered 
rapidly  and  completely.  The  pleuritic  friction  persisted  until  the  eighth 
day  of  the  disease.  Signs  of  adhesion  of  tlie  affected  portions  of  the  j^leura 
were  absent  at  an  examination  made  a  half-year  later. 

The  other  case  occurred  in  a  merchant,  twenty-seven  years  old,  who  was 
admitted  to  the  clinic  on  the  fifth  day  of  the  disease,  and  related  that  cough, 
with  pain  in  the  side  and  a  difficulty  in  breathing,  had  been  the  first  symp- 
toms of  the  attack.  On  admission,  a  large  right-sided  serohemorrhagic 
pleural  effusion  was  discovered.  The  left  lung  was  intact,  with  the  exception 
of  a  few  bronchitic  rales.  The  spleen  was  not  enlarged,  meteorism  was  not 
present,  and  there  were  no  roseolse.  The  only  remarkable  feature  for  a 
case  of  simple  serous  pleurisy  was  the  unusual  temj^erature-course,  which  was 
that  of  a  continued  fever  of  moderate  degree,  with  but  slight  daily  fluct- 
uations. Not  until  the  eighth  day  did  characteristic  pea-soup-like  stools 
appear.  At  the  same  time  enlargement  of  the  spleen  could  be  demonstrated, 
but  roseolse  failed  to  appear  either  at  this  time  or  subsequently  during 
the  course  of  the  disease.  Our  suspicion  that  the  case  was  one  of  pleuro- 
typhoid  was  confirmed  by  the  positive  results  yielded  by  the  Gruber-Widal 
agglutination-test.  The  case  terminated  in  recovery  after  a  most  protracted 
course.  The  effusion,  which  had  to  be  evacuated  by  thoracocentesis  on  the 
twenty-eighth  day,  did  not  reaccumulate. 

My  own  cases  were,  unfortunately,  not  examined  bacteriologically. 
It  is  certain,  however,  that  the  typhoid-bacillus  alone  may  cause  pleu- 
risy.^ The  cases  in  which  this  has  been  demonstrated  fulfil  the  most 
rigorous  requirements  that  could  be  demanded  for  the  establishment  of 
pleurotyphoid  as  an  especial  variety. 

The  so-called  nephrotyphoid  has  also  been  previously  considered 
(pp.  192,  193).  It  was  there  mentioned  that  its  sharp  differentiation 
by  Gubler  and  Robin,  and  especially  the  schematic  classification  of 
Amat,  had,  on  closer  study,  proved  untenable.  Nevertheless,  the 
designation  nephrotyphoid  may  be  applied  to  certain  cases  as  describing 
briefly  and  well  a  peculiarity  of  their  course.  This  is  permissible 
— just  as  has  been  pointed  out  with  regard  to  pneumotyphoid  and 
pleurotyphoid — when  the  commencement,  as  well  as  the  first,  and  even 
the  second,  week  of  the  attack  is  dominated  by  the  clinical  picture  of 

^  Compare  the  French  literature  on  this  point,  p.  257  (see  also  p.  118).  In  addi- 
tion, the  papers  of  ISTetter,  Bull,  de  la  Soc.  med.  de  Paris.,  May  16,  1890.  Loriga  and 
Pensuti,  Riforma  7ned.,  1890,  No.  206.  Weintraud,  Berlin,  klin.  Woch.,  1893,  No. 
15.  Spirig,  Mittheil.  a.  klin.  Instit.  d.  Schweiz,  1894,  1  Reihe,  Heft  9.  Sahli,  Ibid. 
In  all  these  cases  the  typhoid-bacillus  gave  rise  to  purulent  effusions.  That  it  may, 
however,  give  rise  also  to  serofibrinous  effusions  is  shown  by  the  case  of  Fernet,  pre- 
viously mentioned. 


320  TYPHOID  FEVER. 

severe  acute  hemorrhagic  nephritis.  Further  classification,  however, 
so  as  to  include  cases  in  which  the  usual  typhoid  lesions  of  the  viscera 
assume  cliuieally,  and  even  anatomically,  a  very  subordinate  position, 
or  arc  evcu  absent  entirely,  appears  to  me  unjustified.  I  have  observed 
cases  of  nepbrotyphoid  in  which,  at  the  end  of  the  first  or  at  the  begin- 
ning of  the  second  week,  characteristic  diarrhea,  together  with  numerous 
roseolse  and  enlargement  of  the  spleen,  first  appeared ;  and  I  can  recall 
another  case  that  during  life  appeared  to  be  free  from  intestinal  involve- 
ment, hut  ^\•lli('h  at  autopsy  exhibited  abundant  infiltration  of  Peyer's 
patches  in  the  lower  third  of  the  ileum  as  low  as  the  ileocecal  valve. 
The  statement  also  that  the  cases  in  question  almost  always  terminate 
fatally  is  not  correct,  and  is  probably  based  upon  insufficient  data. 

I  have  described  on  page  300  a  case  of  typhoid  fever  of  alwrtive  course 
which  exhibited  perfectly  the  clinical  picture  of  nei)hrotyphoid.  Only 
recently  I  observed  a  second  case  of  the  same  character.  A  merchant, 
twenty-six  years  old,  in  whose  family  3  well-defined  cases  of  typhoid  fever 
of  moderate  severity  had  occurred  within  a  short  time  previously,  was  seized 
with  sensations  of  chilliness,  followed  by  a  step-like  elevation  of  temperature. 
After  the  second  day,  bloody  urine  containing  large  amounts  of  albumin, 
with  great  numbers  of  hyaline,  epithelial,  and  blood-casts,  was  voided.  The 
amount  of  urine  was  greatly  diminished — from  300  to  400  c.c.  in  twenty-four 
hours — and  the  specific  gravity  was  between  1022  and  1028.  Although 
during  the  first  few  days,  in  the  absence  of  other  conspicuous  symptoms, 
nothing  else  than  an  acute  hemorrhagic  nephritis  could  be  assumed  to  be 
present,  nevertheless  the  persistence  of  the  fever,  the  dry  tongue,  and  enlarge- 
ment of  the  spleen,  demonstrable  by  palpation  on  the  fifth  day,  together 
with  the  occurrence  of  the  other  cases  in  the  same  house,  raised  the  question 
as  to  whether  the  condition  might  not  be  dependent  upon  typhoid  infection. 
The  appearance  of  roseolre  on  the  ninth  and  tenth  days  of  the  disease,  and 
their  continued  appearance  in  abundance  up  to  the  fourteenth  day,  con- 
verted the  suspicion  into  certainty.  The  fever  persisted  in  a  moderate, 
continued,  remittent  form  until  the  eighteenth  day,  after  which  the  tempera- 
ture abruptly  declined  to  36.3°  C.  within  twelve  hours.  From  this  time  on, 
convalescence  was  uninterrupted.  The  blood  had  disappeared  from  the 
urine  on  the  eleventh  day  of  the  disease,  and  albumin  and  tube-casts  could 
no  longer  be  demonstrated  after  the  seventeenth  day.  Both  cases  may  be 
considered  as  typical  instances  of  nepbrotyphoid  of  mild  course.  If  I  am 
not  mistaken,  similar  cases  have  been  but  rarely  described  heretofore. 
Possibly  writers  have  been  too  much  influenced  by  the  conception  of  a 
very  severe  course  that  is  considered  typical  of  the  disease. 

The  position  etiologically  of  cases  of  nepbrotyphoid  is  as  yet  unknown. 
TrustAvorthy  bacteriologic  examinations  directed  especially  to  the  par- 
ticipation of  the  typhoid-bacillus  in  the  kidney-lesions  have  not  as  yet 
been  made. 


VARIATIONS  IN  SYMPTOMS  AND   COURSE.  321, 

ASSOCIATION  OF  TYPHOID  FEVER  WITH  OTHER  DISEASES. 
Naturally,  the  question  here  of  especial  significance,  and  the  one  to 
be  considered  above  all  others,  is  as  to  tlie  relation  between  the  other  acute 
infectious  diseases  and  typhoid  fever,  or,  more  definitely  expressed,  the 
manner  in  which  the  organism  under  the  influence  of  the  typhoid-bacillus 
responds  to  the  action  of  the  specific  exciting  causes  of  those  diseases. 
It  has  previously  been  emphasized  in  the  General  Section  (p.  65)  that 
the  existence  of  typhoid  fever,  especially  at  the  period  of  its  febrile  height, 
affords  pretty  certain  protection  against  the  invasion  of  other  acute 
infectious  diseases.  As  a  matter  of  fact,  the  following  statements  will 
show  that  this  is  entirely  true  with  regard  to  some,  while  with  regard  to 
others,  even  though  with  extreme  rarity — exceptio  jirmat  regulam — a 
coincidence  of  the  disease  with  the  fastigium  of  the  typhoid  can  be 
made  out.  The  possibility  of  infection  during  the  stage  of  convales- 
cence, and  also  during  the  period  of  incubation,  is  less  to  be  excluded,  as 
such  infection  appears  to  be  distinctly  more  frequent  at  this  time  than 
at  the  height  of  the  fever. 

Typhoid  Fever  and  the  Acute  Bxanthemata. — The  ques- 
tion as  to  the  coincidence  of  the  acute  exanthemata  with  typhoid  fever 
is  still  obscure  in  many  respects.  The  older  literature  contains  far 
more  numerous  positive  statements  than  the  more  recent  literature. 
Many  of  the  earlier  reports  are  to  be  accepted  with  great  caution,  not 
alone  on  account  of  the  often  most  indefinite  description  of  the  exanthe- 
mata, but  also  on  account  of  the  uncertainty  in  the  diagnosis  of  typhoid 
fever  itself;  for,  as  has  been  pointed  out,  typhus  fever  and  tyjahoid  fever 
were,  until  within  recent  decades,  not  sufficiently  differentiated,  particu- 
larly in  England.  It  can  at  the  present  day  be  stated  with  considerable 
certainty  that  a  number  of  acute  exanthemata  may  definitely  be  asso- 
ciated with  typhoid  fever,  while  this  can  be  denied  of  others,  or,  at 
least,  the  question  is  still  doubtful. 

The  coincidence  of  scarlet  fever  and  typhoid  fever  has  been  recorded 
by  numerous  observers  :  Taupin,'  Forget,^  Murchison,^  and  recently  by 
Eichhorst^  and  Glaser.°  Murchison  presents  the  large  number  of  8 
personal  observations,  all  on  patients  in  the  London  Fever  Hospital,  who 
were  infected  with  scarlet  fever  from  other  patients  in  the  same  ward. 

The  following  history  by  Murchison  ®  may  serve  as  an  illustration  : 

A  police-officer,   twenty-three   years  old,   was  admitted  to  the  London 

^  Jour,  des  conn.  med.  chir.,  1839. 

*  L' enter ite  follicul. ,  Paris,  1840  (both  cited  by  Murchison). 
^  Loc.  cit.,  and  Trans.  Path.  Soc.^  1859,  vol.  x. 

*  Lehrbuch.  '-  Deuisch.  med.  Woch.,  1885,  No.  11,  and  1886,  No.  46. 

^  Typhoid  Diseases,  p.  522,  translated  by  Ziilzer,  Berlin,  1867.  : 

21 


322  TYPHOID  FEVER. 

Fever  Hospital,  Nov.  9,  1857,  after  an  illness  of  from  two  to  three  weeks' 
duration.  He  exhibited  all  the  symptoms  of  typhoid  fever  :  a  red,  glazed, 
and  fissured  tongue,  tympanites,  profuse  watery  diarrhea,  and  an  abun- 
dant roseolous  exanthem.  Fresh  spots  appeared  constantly.  Eight  days 
after  admission  they  were  still  quite  numerous  and  the  diarrhea  persisted. 
There  now  appeared  in  addition  a  general  scarlatinal  eruption  identical  with 
that  of  scarlet  fever,  together  with  a  strawberry-tongue,  with  greatly  enlarged 
papillre,  angina,  and  redness  of  the  fauces.  After  two  days  the  roseolas  were 
still  quite  numerous,  and  the  scarlatinal  eruption  persisted.  Two  days  later 
the  latter  faded,  while  the  typhoid  eruption  persisted  for  a  few  days  more. 
A  week  al^er  the  disappearance  of  the  scarlatinal  eruption  there  was  abun- 
dant desquamation.     The  patient  recovered  rapidly. 

Among  the  cases  of  Gliiser,  one  that  terminated  in  the  death  of  the  patient 
is  especially  instructive.  In  addition  to  the  typhoid  fever,  which  was  char- 
acterized sufficiently  by  roseolte  and  palpable  enlargement  of  the  spleen, 
symptoms  of  scarlet  fever  appeared  at  the  beginning  of  the  second  week. 
The  well-marked  and  characteristic  exanthem,  which  j^ersisted  for  five  days, 
had  l)een  preceded'  immediately  by  angina,  with  dark-red  discoloration  of  the 
mucous  membrane.  The  patient  died  in  consequence  of  scarlatinal  nephritis. 
Examination  of  the  intestine  disclosed,  in  the  neighborhood  of  the  ileocecal 
valve,  the  lesions  of  a  terminated  or  healed  typhoid  process  of  slight  extent. 

I  have  personally  not  as  yet  encountered  the  coincidence  of  the  two 
diseases,  probably  because  I  have  always  practised  the  rigid  isolation 
of  tvphoid  patients,  even  of  adults,  from  patients  suffering  from  scarlet 
fever.  With  regard  to  the  order  in  time  in  which  the  diseases  succeed 
each  other,  apparently  in  the  great  majority  of  instances  scarlet  fever 
occurs  secondarily.  It  then  generally  appears  in  the  later  stages  of 
typhoid  fever,  often  only  during  convalescence,  but  even  in  these  cases 
the  onset  is  frequently  so  early  in  convalescence  that  the  period  of  infec- 
tion must  be  referred  to  the  febrile  stage  of  the  typhoid  fever.  From  a 
diagnostic  point  of  view,  the  combination  in  question  presents  con- 
siderable difficulty.  It  is  easily  conceivable  that  certain  cases  of  hemor- 
rhagic variola  with  a  scarlatiniform  initial  exanthem  and  a  typhoid 
course,  and  also  certain  scarlatinoid  erythemata,  especially  those  attend- 
ing cryptogenetic  septicemias,  may  be  confused  with  the  combination  of 
diseases  now  under  discussion. 

The  coincidence  of  rotheln  with  typhoid  fever  has  been  mentioned 
by  Taupin,  Barthez  and  Rilliet,  and  others.  With  all  due  regard  for 
the  acumen  of  these  observers,  especial  caution  would  seem  necessaiy 
in  this  connection,  particularly  on  account  of  the  danger  of  confusion 
of  this  condition  with  transient  punctate  erythemas,  and  especially  with 
drug-exanthemas.  It  is  doubtful  whether  measles  and  typhoid  fever 
may  occur  together. 

In    my   experience^   variola   and   typhoid   fever    appear    almost   to 

1  See  Curschmann,  "Die  Pocken,"  von  Zieynssen's  Handbuch,  2d  ed.,  1878.  Th. 
Simon,  Berlin.  Jdin.   Woch.,  1872,  No.  11. 


VARIATIONS  IN  SYMPTOMS  AND   COURSE.  323 

exclude  each  other  during  the  febrile  stage  of  each  disease.  I  have 
repeatedly  seen  convalescents  from  typhoid  fever  attacked  by  small-pox, 
but  whenever  the  beginning  of  the  attack  of  variola  was  determined,  it 
could  be  established  that  the  infection  must  have  taken  place  in  the 
afebrile  period  of  convalescence  from  typhoid  fever,  even  admitting  the 
longest  possible  period  of  incubation  for  the  variola. 

Of  6  convalescents  from  typhoid  fever  infected  with  small-pox  whom 
observed  in  the  year  1870-71  in  the  hospital  at  Mainz,  which  at  that  time 
was  overcrowded,  the  primary  stage  began  iu  2  on  the  nineteenth,  in  2 
others  on  the  seventeenth,  and  in  1  each  on  the  sixteenth  and  the  fourteenth 
day  after  they  had  exhibited  the  last  febrile  elevation  of  temperature  attrib- 
utable to  the  typhoid  fever.  A  case,  apparently  of  actual  coincidence  of 
variola  and  typhoid  fever,  has  been  reported  by  Th.  Simon,  who  in  the  same 
communication  states  that  it  is  his  impression  that  during  the  epidemic  of 
small-pox  that  prevailed  in  Hamburg  at  that  time,  the  cases  of  typhoid 
fever  which  occurred  exhibited  usually  well-marked  development  of  the 
roseolous  exanthem. 

I  have  personally  observed  vaccine-pustules  during  the  febrile  stage 
of  typhoid  fever  in  a  few  cases.  The  patients  were  individuals  who 
had,  during  the  period  of  incubation  of  typhoid  fever,  a  greater  or  less 
time  before  the  appearance  of  its  first  symptoms,  been  subjected  to  pro- 
tective vaccination.  These  cases  prove  that  at  a  period  in  which  the 
organism  is  already  under  the  influence  of  the  typhoid  infection,  even 
though  in  but  a  latent  degree,  the  activity  of  the  excitants  of  vaccinia 
is  not  abolished. 

Typhoid  Fever  and  Other  Acute  Infectious  Diseases. — 
The  Septicemic  Variety. — This  severe  form  of  disease,  which  has  as 
yet  been  but  little  investigated,  appears  to  be  the  result  of  mixed  infec- 
tion with  Bacillus  typhosus  and  Streptococcus  pyogenes.  The  cases  are 
said  to  be  characterized  by  high  fever,  unusually  marked  disturbance  of 
the  general  condition,  considerable  and  early  enlargement  of  the  spleen, 
the  mesenteric  and  the  bronchial  glands,  with,  it  has  been  stated,  often 
only  slightly  developed,  and,  according  to  some  writers,  at  times  even 
wholly  absent,  specific  intestinal  lesions.  The  pathogenic  micro-organisms 
are  demonstrable  especially  in  the  spleen  and  the  lymphatic  glands. 
They  have  been  repeatedly  found  also  in  the  liver,  the  brain  and  the 
meninges,  the  lungs,  and  in  the  blood,  especially  the  blood  of  the  lungs. 
In  all  the  cases  heretofore  reported  the  invasion  with  streptococci 
appears  to  have  been  secondary.  Generally,  purulent  processes  and 
tonsillar  angina,  otitis  media,  phlegmons,  and  the  like,  due  primarily 
and  solely  to  the  streptococci,  can  be  demonstrated  after  death ;  while 
in  other  parts,  as,  for  instance,  the  spleen,  the  mesenteric  glands,  and 
the  liver,  both  varieties  of  pathogenic  micro-organisms  may  be  found 


324  TYPHOID  FEVER. 

together  ;  and  in  still  other  organs,  as,  for  instance,  the  intestinal  follicles, 
typhoid-bacilli  are  frequently  found  alone. 

The  course  of  the  cases   in   (][uesti()n   a})pears  to   be   most  virulent. 
Almost  all  tlie  cases  hitherto  observed  have  terminated  fatidly.      It  is 
correctly  maintainetl,  especially  upon  the  basis  of  experimental  observa- 
tion, that  the  combined  activity  of  both  micro-organisms  is  especially 
dangerous — far  more  so  than  that  of  either  alone.      I   have  pcrsc^nally 
no  experience  with  this  variety  of  typhoid  fever.      Tlie  first  and  most 
important  statements  relating  to  it  emanate  from  Frcncli  investigators — 
Chantemessc  and  ^^'idal,    Vaillard  and  Vincent,'   and  others.       They 
appropriately  designate   it    as  the  Forme  septick)iiquc   gmeralisee.     In 
Germany,  AVassermann^  has  published  similar  observations.     He  was 
able  to  demonstrate  the  stre])tococci  in  the  blood  during  life.      Further 
investigation  will  have  to  determine  whether,  as  is  highly  probable,  a 
considerable  number  of  cases  of  typhoid  fever  of  malignant,  fulminant, 
hemorrhagic,  or  hyperpyretic  course  do  not  belong  etiologically  in  this 
category.     The  cases,  however,  in  which  the  agminate  and  the  solitaiy 
follicles  of  the  intestine  are  found  entirely  free  from  specific  infiltration, 
although  at  the  same  time  typhoid-bacilli,  together  with  streptococci, 
are  said  to  be  present  in  the  other  organs,  require,  in  my  opinion,  careful 
reinvestigation,  which  should  be  directed  especially  to  possible  confusion 
of  the  typhoid-bacillus  with  the  Bacterium  coli. 

These  cases  are  to  be  separated  from  those  cases  of  typhoid  fever 
which,  during  the  defervescence  of  the  fever  or  during  convalescence, 
acquire  a  secondary  general  infection  with  one  of  the  varieties  of  pyo- 
genic cocci.  The  general  infection  is  probably  favored  by  the  lowered 
general  resistance  of  the  patient.  The  point  from  which  the  organisms 
gain  entrance  to  the  general  circulation  is  usually  some  localized  focus 
of  inflammation.  In  a  case  lately  occurring  in  the  Johns  Hopkins 
Hospital  the  patient,  during  the  end  of  an  attack  of  typhoid  fever, 
suffered  from  a  large  carbuncle  on  the  back.  Cultures  taken  from  the 
blood  during  the  height  of  the  attack  of  typhoid  showed  the  presence 
of  typhoid-bacilli,  but  cultures  taken  ten  days  after  the  onset  of  the 
carbuncle  sliowed  a  pure  growth  of  Staphylococcus  aureus.  Cultures 
were  repeatedly  taken,  with  similar  results,  before  death,  which  occurred 
after  several  weeks  with  symptoms  of  general  septicemia. 

Of  other  conditions  allied  to  septic  processes,  erysipelas  is  worthy 
of  special  consideration.      The  occurrence  of  this,  ag  has  previously  been 

1  See  Chantemesse,  "Typhoid  fever,"  Traite  de  med.,  publ.  par  Charcot, 
Bouchard  et  Brissaud,  t.  i.  Brouardel  and  Thoinot,  pp.  293,  294.  Vincent,  Ann^ 
de  rinstitid.  Pasteur,  1893,  No.  2.  '^  Charitc-Annalen,  1894,  t.  xix. 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  325 

mentioned,  is  not  excluded  by  the  presence  of  typhoid  fever.  Typhoid 
patients  at  any  stage  may,  on  the  contrary,  he  attacked  by  erysipelas. 
If  this  is  more  common  toward  the  end  of  the  febrile  period  and  during 
convalescence,  the  principal  reason  for  this  circumstance  resides  in  the 
fact  that  at  this  time  bed-sores  and  other  ulcerative  processes  constitute 
especially  favorable  starting-points  for  the  process.  I  have  observed 
facial  erysipelas  develop  only  with  considerable  rarity  at  the  height  of 
the  disease.  This  rarity  is  especially  striking  in  view  of  the  frequency 
with  which  erosions  occur  at  the  nasal  orifice  and  the  lips,  and  the  way 
in  which  these  are  maltreated  at  the  hands  of  the  patient  himself. 
Whether  this  rarity  is  due,  in  part  at  least,  to  the  fact  that  in  cases  of 
typhoid  fever  at  the  height  of  the  pyrexia  the  erysipelatous  infection 
is  somewhat  more  severe  than  in  healthy  individuals,  may  for  the 
present  be  considered  undecided.  Griessinger^  also  has  noted  fatal 
erysipelas  in  but  2  per  cent,  of  500  cases  observ^ed  at  Zurich. 

The  coincidence  of  typhoid  fever  with  Asiatic  cholera  is  mentioned 
especially  by  Trousseau  and  a  niunber  of  modern  French  clinicians. 
If,  however,  the  subject  be  investigated,  the  condition  appears  in  most 
cases  to  be  only  one  of  infection  with  cholera  of  convalescents  from 
typhoid  fever,  or,  conversely,  of  typhoid  infection  in  persons  who  a 
short  time  previously  had  recovered  from  cholera.  Actual  coinci- 
dence of  both  diseases  appears,  on  the  other  hand,  to  be  extremely 
rare,  if  it  occurs  at  all. 

Of  the  simultaneous  existence  of  dysentery  and  typhoid  fever 
we  have  knowledge  only  through  medical  reports  from  the  tropics. 
Here,  also,  the  condition  appears  to  consist  essentially  in  an  invasion  of 
dysentery  durmg  convalescence  from  typhoid  fever.  Cases  in  which 
dysentery  has  developed  at  the  height,  or  in  the  second  half,  of  the 
febrile  stage  should  be  accepted  with  great  caution  in  the  absence  of 
careful  post-mortem  examination.  Colotyphoid  with  tj^Dhoidal  intes- 
tinal lesions  extending  far  down  to  the  rectum  may,  as  I  have  per- 
sonally observed,  give  rise  to  symptoms  simulating  those  of  dysen- 
tery. 

The  coincident  occurrence  of  diphtheria  and  typhoid  fever,  par- 
ticularly during  severe  epidemics,  is  mentioned  frequently,  especially 
by  older  writers.  Doubtless  the  throat  condition  is  principally  one  of 
diphtheria  in  the  older  anatomic  sense.  Adequate  recent  bacteriologic 
investigation  has,  so  far  as  I  know,  not  yet  been  made.  I  have  per- 
sonally not  seen  diphtheria — in  the  current  etiologic  sense,  with  the 
demonstration  of  the  bacillus  of  Loffler — occur  as  a  complication  of 

^  Loc.  cit. 


326  TYPHOID  FEVER. 

typhoid  fever.  I  ^voukl  warn  especially  against  confusion  with  the 
specific  typhoid  angina  previously  mentioned. 

A  not  insignificant  rdlc  is  played  in  the  tropics,  in  North  America, 
China,  and  Ja})an,  and  in  malarious  regions  on  the  continent  of  Europe, 
by  cases  that  have  been  attributed  to  mixed  infection  m  ith  typhoid  fever 
and  malaria,  and  that  have  in  France  been  designated  ty})homalarial 
fever.  From  the  existing  descriptions  (Kelsch  and  Kicuer,  Scheube, 
and  others  *),  the  cases  represent  an  admixture  of  typhoid  symptoms 
— roseolse,  pea -soup-like  stools,  stupor,  diffuse  bronchitis — with  the 
febrile  course  peculiar  to  intermittent  fever.  Accordingly  as  the  one 
or  the  other  of  the  two  aifcctions  predominates  or  recedes  temporarily 
or  during  the  entire  course  of  the  disease,  the  most  varied  clinical  pict- 
ure, often  difficult  of  interpretation,  develops.  The  course  of  this  form 
of  disease  appears  to  be  quite  severe,  and  its  prognosis  is  said  to  be  far 
more  grave  than  that  of  simple  typhoid  fever. 

Lyon,-  who  has  studied  the  question  of  combined  typhoid  and 
malarial  infection  and  the  so-called  typhomalarial  fever,  concludes  that 
in  regions  where  both  are  common,  it  is  probable  that  combined  infec- 
tions not  infrequently  occur,  but  that  such  cases  are  certainly  not  the 
ones  that  have  been  described  in  the  United  States  under  the  name 
"  typhomalarial "  fever.  It  is  certain  that  cases  of  intermittent  fever 
are  incorrectly  mcluded  in  this  group,  that,  without  the  influence  on  the 
body  of  the  typhoid-bacillus  in  addition  to  the  plasmodia,  are  attended 
with  typhoid  symptoms,  stupor,  delirium,  prostration,  etc. ;  and,  con- 
versely, some  physicians  practising  in  malarious  regions  are  in  the  habit 
of  considering  cases  of  typhoid  with  a  predominant  intermittent  type  of 
fever  as  influenced  by  malaria.  It  should  be  emphasized  that  before  such 
combined  infection  is  considered  as  demonstrated,  the  plasmodia  should 
be  found  in  the  blood,  as  well  as  a  positive  Gruber-Widal  agglutina- 
tion-test obtained.  Italian  physicians  and,  in  France,  Jaccoud^  have 
described  as  the  sudoral  type  of  typhoid  a  form  of  disease  occurring 
especially  in  Italy  and  Malta,  in  which,  in  addition  to  febrile  and 
typhoid  symptoms,  intermittent  sweating  assumes  a  prominent  position. 
Jaccoud  considers  it,  with  good  reason,  as  a  peculiar  variety  of  typho- 
malarial fever.  Canine  fever  also — fievre  des  chiens — which  has  been 
described  in  Bosnia  and  Herzegovina  by  a  number  of  observers  (Pick, 
Karlinski),  appears  also  to  belong  in  this  category.      Probably  the  condi- 

1  Maladies  des  pays  chaiids,  Paris,  1889.     Scheube,  Krankheiten  der  warmen  Lan- 
der^ Jena,  1896.     See  the  rather  extensive  literature  in  the  papers  of  both  writers. 
'  Johns  Hopkins  Hasp.  Rep.,  vol.  viii. 
^  Clin.  med. 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  327 

tion  is  one  of  typhoid  fever  in  individuals  who,  a  short  time  previously, 
had  recovered  from  malaria. 

Karlinski^  has  described  an  interesting  case  of  anthrax  combined 
with  typhoid  fever,  which  was  subjected  to  careful  bacteriologic  exam- 
ination. 

Cases  of  the  coincident  existence  of  rheumatic  polyarthritis  with 
typhoid  fever,  which  have  exceptionally  been  reported,  are  to  be  viewed 
skeptically,  because,  on  the  one  hand,  we  are  without  pathognomonic 
signs  of  the  first-named  disease,  and  especially  without  knowledge  of  its 
specific  exciting  factor ;  and,  on  the  other  hand,  it  must  always  be  borne 
in  mind  that  typhoid  fever  itself,  and  other  conditions  closely  resembling 
it  superficially,  may  at  times  be  attended  with  multiple  inflammatory 
aifections  of  the  joints.  Among  the  latter  conditions  certain  cases  of 
cryptogenic  septicopyemia  and  infectious  osteomyelitis  should  especially 
be  kept  in  mind.  I  have  never  been  able  to  convince  myself  of  the 
occurrence  of  cases  exhibiting  a  coincidence  of  true  rheumatic  poly- 
arthritis with  typhoid  fever. 

Chronic  Diseases  and  Typhoid  Fever. — Numerous  refer- 
ences have  previously  been  made  to  the  relation  between  chronic  diseases 
and  typhoid  fever.  I  may  again  call  attention  especially  to  the  state- 
ments with  reference  to  diseases  of  the  nervous  system,  the  circulatory 
organs,  the  lungs,  and  especially  to  tuberculosis.  Among  constitu- 
tional diseases,  special  attention  has  been  paid  to  the  combination  of 
diabetes  mellitus  with  typhoid  fever.^  As  occurs  in  the  majority 
of  diseases  attended  with  chronic  emaciation,  so  even  severe  cases  of 
typhoid  fever  in  diabetic  patients  may  be  attended  with  remarkably  low 
temperature.  I  have  personally  observed  such  an  instance  in  a  patient, 
forty-three  years  old,  who  died  as  the  result  of  the  attack  of  typhoid 
fever  at  the  beginning  of  the  third  week ;  no  special  complications 
occurred,  and  the  temperature  throughout  the  entire  course  of  the 
attack  did  not  exceed  39°  C,  and  reached  this  level  only  on  three 
evenings.  Low  temperature  in  these  cases  is  therefore  not  in  itself  to 
be  considered  as  of  favorable  significance.  Of  6  cases  collected  by 
Ebstein,  death  occurred  in  4.  It  is  worthy  of  note  that  the  excretion 
of  sugar  undergoes  little  change  during  the  course  of  the  attack  of 
typhoid  fever,  and  generally  lessens  only  toward  the  fatal  termination. 

1  Berlin,  klin.   Woch.,  1888. 

^  Griessinger,  Arch.  d.  Heilk.,  1862,  3.  Jahrg.  Bamberger,  Wurzburg.  med.  Zeit., 
1863,  Bd.  iv.  Gerhardt,  Correspondenzbl.  d.  cerztl.  Vereinsf.  Thuringen,  1874,  Bd.  iii. 
Eyba  and  Plumer,  Prag.  Viertelj.,  1877.  Ebstein,  Deutsch.  Arch.  f.  klin.  Med.,  Bd. 
XXX.  (This  paper  contains  a  complete  clinical  discussion  of  the  subject,  together  with 
full  reference  to  the  literature.) 


328  TYPHOID  FEVER. 

On  the  other  hand,  the  iron-chlorid  reaction  of  Gerhardt  appears  to 
iinderfTO  a  considerable  intensification  with  the  commencement  of  the 
fever  (Gerhardt,   Ehsteiu). 

Among  the  chronic  intoxications,  reference  may  be  made  to  mor- 
phinism and  alcohoHsm.  So  far  as  I  know,  attention  lias  hitherto  not 
been  called  to  the  behavior  of  persons  addicted  to  morphin  toward 
typhoid  fever,  I  have  studied  carefully  2  eases  of  tyjihoid  fever  in 
such  persons,  and  have  been  impressed  especially  with  the  lessened 
powers  of  resistance  of  such  individuals.  Both  patients — the  one  a 
woman,  thirty-two  years  old,  and  the  other  a  man,  thirty-seven  years 
old — died  as  a  result  of  the  disease  on  the  fifteenth  and  the  eighteenth 
day,  respectively.  The  absolute  sleeplessness  from  the  beginning,  the 
constant  marked  restlessness,  and  the  early  and  unusually  pronounced 
subsultus  tendinum  and  floctitation,  so  that  in  the  case  of  the  woman 
the  condition  was  strongly  suggestive  of  a  case  of  chorea,  were  con- 
spicuous and,  of  course,  easily  explainable.  The  temjierature,  in  com- 
parison with  the  severity  of  the  attack  in  other  respects,  was  low,  just 
as  in  the  combination  of  diabetes  and  typhoid  fever. 

Chronic  alcoholics  are  seriously  threatened  when  attacked  with 
tvphoid  fever.  In  them,  also,  the  temperature-course,  unless  complica- 
tions exert  an  elevating  influence,  generally  pursues  a  rather  low  level. 
This  fact,  how^ever,  just  as  in  the  case  of  diabetics  and  persons  addicted 
to  morphin,  in  nowise  alters  the  prognosis.  Alcoholics  also  exhibit 
diminished  resistance  to  the  disease,  and  generally  succumb  to  it  within 
a  short  time.  I  have  observed  a  mortality  of  34  per  cent,  for 
drunkards  suffering  from  typhoid  fever  at  Hamburg.  The  lessened 
powers  of  resistance  in  these  patients  are  especially  appreciable  in  the 
action  of  the  heart.  Even  from  the  beginumg  the  pulse  is  likely  to  be 
disproportionately  frequent,  and  often  becomes  distinctly  smaller,  feebler, 
and  irregular  as  early  as  the  middle  or  close  of  the  first  or  the  beginning 
of  the  second  week.     Dilatation  of  the  heart  also  develops  quite  early. 

With  regard  to  the  vascular  system,  the  special  tendency  to  hemor- 
rhages is  to  be  considered.  Drunkards  exhibit  more  frequently  than 
other  patients  copious  nose-bleed,  and  are  often  attacked  unusually 
early  by  severe  intestinal  hemorrhage,  the  source  for  which  is  eventually 
found  to  consist  in  sponginess,  friability,  and  hemorrhagic  congestion  of 
the  patches  that  have  not  yet  undergone  sloughing.  That  the  exces- 
sively severe  cases  of  hemorrhagic  typhoid  fever  occur  with  especial 
frequency  in  drunkards  has  been  previously  mentioned. 

As  a  further  peculiarity  of  typhoid  fever  in  alcoholics,  the  unusually 
profound  involvement  of  the  entire  nervous  system  is  yet  to  be  men- 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  329 

tioned.  The  clinical  picture  of  the  "  ataxic  adynamic  variety  "  appears 
early  under  these  conditions,  with  the  early  development  of  profound 
disturbance  of  consciousness,  great  restlessness,  and  severe  delirium. 
Symptoms  of  actual  dehrium  tremens,  however,  (jccur — in  comparison 
with  their  frequency  in  erysipelas,  pneumonia,  and  other  acute  infectious 
diseases — with  extreme  rarity.  It  may  further  be  mentioned  at  this 
point  that  albuminuria,  not  rarely  also  hemorrhagic  nephritis,  occurs 
especially  early  and  in  marked  degree  in  drunkards.  Under  the  dele- 
terious influence  of  early  cardiac  weakness,  the  latter  may  readily  give 
rise  to  fatal  uremia. 

VARIATIONS   EST   COURSE   DEPENDING   UPON    CONSTITUTION, 

SEX,    AND  AGE. 

Constitution. — Although  definite  knowledge  is  wanting  with 
regard  to  the  intimate  nature  of  that  which  is  designated  constitution,  it 
may  nevertheless  be  stated  that  the  course  of  an  attack  of  typhoid  fever 
stands  in  a  most  remarkable  relation  to  that  which  in  general  is  so 
designated.  It  has  been  seen  that  young  vigorous  individuals  of  good 
constitution  are  attacked  with  especial  frequency  by  typhoid  fever, 
although  they  recover  most  readily  and  uninjured  after  a  longer  or 
shorter  course.  Tough — that  is,  the  spare,  muscular — individuals  with 
healthy  internal  viscera  exhibit  an  especially  favorable  relation  in  this 
connection.  On  the  other  hand,  the  obese  are  especially  threatened,  as 
every  experienced  physician  knows.  Only  too  often  have  the  friends  of 
a  corpulent  young  man  or  a  blooming,  flourishing  young  woman  placed 
too  much  dependence  upon  this  deceptive  appearance.  However  much 
the  physician  tries  to  suppress  his  anxious  fears,  he  sees  them  confirmed 
over  and  over  again,  as  such  persons,  when  attacked  with  typhoid 
fever,  do  not  hold  out.  They  often  exhibit  unusually  high  and 
uninterrupted  fever,  and  they  are  early  overcome  by  sopor,  coma,  and 
other  severe  symptoms  referable  to  the  central  nervous  system.  The 
most  unfavorable  feature  is  the  behavior  of  the  heart,  which,  often 
as  early  as  the  first  week,  exhibits  signs  of  deficient  power,  so  that 
the  course  of  the  disease  is  almost  from  the  beginning  dominated  by 
the  signs  of  cardiac  weakness.  Upon  this  is  dependent  the  fact  that 
the  typhoid  bronchitis  of  the  obese  early  attains  a  severe  degree  and  a 
wide  distribution,  and  that  a  special  tendency  to  the  development  of 
pulmonary  stasis  and  hj^ostatic  pneumonia  exists. 

Sex. — General  experience  teaches  that  no  material  difi'erence  be- 
tween the  two  sexes  appears  to  exist  in  regard  to  the  tendency  to  be 
attacked  by  typhoid  fever.     My  own  experience,  based  upon  a  large 


330  TYPHOID  FEVER. 

number  of  cases,  agrees  with  this.  Also  with  reference  to  the  prog- 
nosis of  the  disease,  uo  radical  difference  can  be  discovered  to  exist. 
While  Liebermeister  at  Basle  observed  a  raortality  of  12  per  cent,  in 
males  and  of  14.8  per  cent,  in  females  ;  in  the  medical  clmic  at  Munich,^ 
for  the  years  from  1874  to  1877,  on  the  contrary,  the  mortality 
among  the  males  was  considerably  greater.  Goth  also  reports  from  the 
clinic  at  Kiel  a  mortality  of  5.4  per  cent,  in  males  and  of  4.5  per  cent, 
in  females.  I  have  personally  found  this  relation  to  vary  in  different 
cities.  Thus,  at  Hamburg  we  had  a  mortality  of  9.9  per  cent,  in  males 
and  of  8.5  per  cent,  in  females  ;  while  our  statistics  at  Leipsic  disclosed 
14.7  per  cent,  for  the  former  and  15.2  per  cent,  for  the  latter. 

In  certain  cities  and  in  certain  classes  of  society,  on  the  other  hand, 
differences  in  nutrition,  in  mode  of  life,  and  in  occupation  appear  to 
cause  appreciable  differences  with  regard  to  the  character  of  the  course 
and  the  termination  of  the  attack  in  the  two  sexes.  In  this  connection, 
the  important  role  that  alcoholism  plays  in  men  is  especially  to  be 
considered.  In  women,  naturally — although  this,  on  the  whole,  makes 
no  impression  on  the  statistics — the  sexual  functions  are  of  considerable 
influence.  It  has  already  been  seen  how  greatly  threatened  are  pregnant 
and  puerperal  women  attacked  by  typhoid  fever.  Also  during  the  first 
period  of  lactation  the  powers  of  resistance  have  appeared  to  me  to  be 
somewhat  diminished,  while  at  a  later  period  of  lactation  othersvise 
well-constituted  women  react  to  the  disease  as  those  not  lactating  do. 

Age. — The  differences  dependent  upon  age  are  far  more  important. 
In  general  it  may  be  said  that  the  course  and  the  termination  become 
progressively  more  unfavorable  with  increasing  years,  so  that  children — 
except  during  the  earliest  period  of  life — occupy  by  far  the  most  favor- 
able situation ;  while  as  early  as  the  beginning  or  middle  of  the  fifth 
decade  the  influence  of  age  begins  to  make  itself  manifest.  The 
moderate  course  of  the  disease  occurs  between  the  fifteenth  and  thirty- 
fifth  years.  The  so-called  typical  picture  of  the  disease  is  generally 
drawn  from  cases  during  this  period.  The  peculiarities  of  typhoid 
fever  in  children  and  those  of  the  disease  in  advanced  life  deserve 
especial  consideration. 

Typhoid  Fever  in  Childhood. ^ — Apart  from  the  earliest  period  of 
life,  which  will  receive  special  consideration  later,  children  are  not  much 
less  predisposed  to  typhoid  fever  than  adults.    This  predisposition  begins 

^  Beetz,  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  xvi.,  xvii.,  xviii. 

^  The  personal  experience  upon  which  the  followine;  statements  are  based  is  derived 
from  the  records  of  613  cases,  and  upon  the  careful  observation  and  treatment  of  295 
cases  in  hospital  and  private  practice. 


VARIATIONS  IN  SYMPTOMS  AND   COURSE.  331 

slowly  to  make  itself  noticeable  as  early  as  between  the  fourth  and  the 
fifth  year.  A  further  considerable,  and  from  this  time  on  progressive, 
increase  in  the  morbidity  generally  occurs  between  the  ninth  and  the 
tenth  year. 

Attention  should  be  called  to  the  fact  that  the  experiences  of  private 
practice  and  the  statistical  statements  referring  to  the  general  population 
are  far  more  reliable  in  this  connection  than  the  data  obtained  from 
general  hospitals.  Naturally,  relatively  more  children  than  adults  are 
treated  at  home,  and  of  those  attacked,  a  considerable  number  in  large 
cities  enter  the  children's  hospitals.  Accordingly,  the  figures  exhibited  ljy 
the  general  hospital  statistics  are  too  low. 

The  character  of  the  disease  in  children  is,  on  the  whole,  milder 
than  in  adults.  They  are  more  resistant  to  the  intoxication,  and 
overcome  its  efiects  more  readily  and  more  completely.  With  this 
correspond  the  especially  frequent  abbreviation  of  the  disease  in  chil- 
dren, particularly  of  its  febrile  stage,  and  the  much  larger  number  of 
recoveries,  even  in  protracted,  severe  cases. 

The  cases  m  which  the  disease  is  of  shorter  duration  manifest  them- 
selves in  various  ways.  In  a  portion  of  the  cases,  the  shorter  duration 
appears  to  be  dependent  upon  the  fact  that  the  individual  stages, 
although  they  exhibit  their  typical  development,  pursue  a  shorter 
course.  A  still  larger  number  belong  to  the  varieties  of  typhoid 
fever  that  have  been  designated  abortive,  mild  and  mildest,  which 
have  already  been  adequately  described.  Cases  of  typical  or  greatly 
protracted  course  are  less  common  in  children. 

With  regard  to  the  febrile  symptoms,  and  especially  the  height  of 
the  body-temperature,  the  curve  appears  in  general  to  pursue  a  some- 
what lower  level.  In  general  the  elevations  of  the  temperature  are  less 
in  young  children  than  in  older  ones.  After  the  twelfth  year  of  life, 
the  curve,  with  relation  to  its  form  and  height,  progressively  approaches 
that  of  adults.  The  tendency  to  a  markedly  remittent  curve,  which 
makes  itself  apparent  in  the  cases  of  abbreviated  course  and  of  moderate 
severity,  and  especially  in  those  of  protracted  course,  is  noteworthy  of 
typhoid  fever  in  children.  Cases,  however,  in  which  from  the  beginning 
the  curve  exhibits  such  marked  and  regular  fluctuations  as  to  be  sugges- 
tive of  malaria  are  distinctly  less  common  in  children  than  in  adults. 
The  older,  particularly  English  and  French,  clinicians  (Abercrombie, 
Wendt,  Chomel,  and  others)  early  described  as  infantile  remittent  fever 
a  symptom-complex  occurring,  as  the  name  suggests,  preferably  during 
childhood.  This  was  at  first  considered  a  special  disease,  but  was  subse- 
quently recognized,  through  the  labors  of  Taupin,  Barthez  and  RilHet, 
West  and  Murchison,  as  typhoid  fever  of  peculiar  course.    At  that  time. 


332  TYPHOID  FEVER. 

when  the  real  nature  of  infantile  remittent  fever  was  not  understood, 
and  also  the  abortive  and  mild  forms  were  but  imperfectly  known, 
typhoid  fever  in  children  was  considered  rare. 

In  contrast  with  the  usual  behavior  of  the  body-temj^erature,  the 
pulse-rate  is  from  the  beginning  exceedingly  high,  especially  in  early 
childhood.  Only  in  older  children,  after  the  twelfth  year,  does  the 
pulse- frequency  again  approach  that  of  adults.  In  such  children 
dicrotism  is  occasionally  observed  in  the  course  of  the  second  or  the 
third  week,  while  I  have  with  only  extreme  rarity  encountered  this 
manifestation  in  younger  children.  The  condition  of  the  heart,  of  all 
the  organs,  exhibits  most  distinctly  the  greater  resisting  power  of  the 
child  to  the  action  of  the  toxins.  Cardiac  weakness  occurs  much  less 
commonly,  and  only  in  cases  of  especially  long  and  severe  course. 
Irregularity  of  the  heart's  action,  as  well  as  irregularity  of  the  pulse  in 
force  and  rhythm,  is  observed  almost  only  in  the  quite  exceptional  cases 
complicated  by  endocarditis,  myocarditis,  or  pericarditis. 

With  regard  to  the  manifestations  on  the  part  of  the  skin,  especially 
the  roscolse,  they  exhibit  little  deviation  from  those  in  adults.  I  know 
well  that  most  diverse  statements  have  been  made  by  writers  on  pedi- 
atrics, so  that,  for  instance,  Rilliet  and  Barthez  consider  them  as  rare, 
while  Taupin  and  others  consider  them  as  occurring  with  almost  greater 
frequency  than  in  later  life.  Probably  these  diiferences  are  attributable 
to  accidental  local  and  temporal  conditions.  During  some  epidemics  or 
endemics  the  roseolse  appeared  also  to  me  to  be  less  pronounced,  while 
at  other  times  they  were  especially  constant  and  abundant.  If,  how- 
ever, I  take  the  average  of  many  years'  observation,  I  believe  I  am 
unable  to  appreciate  any  difference  from  the  conditions  in  adults. 
Possibly  it  may  be  stated  as  noteworthy  that  the  roseolse  generally 
appear  somewhat  later  in  children,  generally  in  slighter  or  but  moderate 
profusion,  but  in  individual  instances  often  more  markedly  developed. 
I  have  been  struck,  in  a  number  of  children  between  the  ages  of  five 
and  ten  years,  by  the  especial  size  of  the  roseolse  and  their  more  marked 
elevation  above  the  surface  of  the  skin,  and  by  their  tendency  to  become 
confluent. 

Almost  the  same  that  has  been  said  of  the  roseolse  is  applicable  also 
to  sudamina.  Particularly  in  middle  childhood,  between  the  fifth  and 
tenth  years,  I  have  not  rarely  observed  upon  the  chest,  the  abdomen, 
and  down  to  the  thighs,  rather  abundant,  in  part  even  confluent, 
miliaria,  with  subsequent  desquamation  of  the  skin  during  conva- 
lescence, the  desquamation  being  often  of  a  branny  character,  and  here 
and  there  even  occurring  in  sheets  of  considerable  size. 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  333 

Bed-sores  are  much  rarer  in  well-nursed  children  than  in  adults. 
Noma  was  formerly  noted  rather  fre(juently  as  a  complication,  esj)ecially 
in  young  children,  while  at  the  present  day  the  condition  is  scarcely  ever 
referred  to.  Upon  the  tendency  on  the  ])art  of  children  suffering  from 
typhoid  fever  to  pick  at  the  nose  and  at  the  lips  is  dependent  the  fact 
that  extensive  bleeding  fissures  and  excoriations  covered  with  crusts 
frequently  occur. 

The  abdomen  is  more  likely  to  be  distended  in  children,  but  gen- 
erally only  in  moderate  degree,  and  rarely  so  greatly  as  in  adults. 
Children  complain  more  frequently  than  the  latter  of  abdominal  pain. 
Vomiting  and  retching  are  not  very  rare  manifestations  of  the  first  few 
days  of  the  disease  in  young  children.  With  reference  to  the  number 
and  the  consistency  of  the  stools,  the  conditions  in  children  exhibit  little 
peculiarity.     Possibly  diarrhea  is  somewhat  more  constant  than  in  adults. 

Distinct  peculiarities  exist,  however,  with  regard  to  the  serious  intes- 
tinal manifestations  of  hemorrhage  and  perforative  peritonitis.  Both  are 
less  common  in  children,  especially  in  early  and  middle  childhood,  than 
somewhat  later  in  life  (Taupin,  Rocher,  Rilliet  and  Barthez,  Henoch, 
Gerhardt,  Biedert).  While  among  adults  I  have  at  times  encountered 
hemorrhage  in  10  per  cent,  and  even  more,  in  children  I  have  observed 
it  in  only  1  per  cent.  Biedert  also  states  that  in  a  collection  of  435 
cases  of  typhoid  fever  in  children  he  found  intestinal  hemorrhage  in  not 
quite  4  per  cent.  Perforative  peritonitis  is  comparatively  even  rarer. 
This  peculiarity  finds  a  satisfactory  explanation  in  the  anatomic  condi- 
tions in  the  bowel.  In  children  the  infiltration  of  the  agminate  and 
solitary  follicles  is  in  general  far  less  marked.  Accordingly,  sloughing 
and  ulceration  will  occur  under  such  circumstances  more  rarely,  and,  if 
at  all,  in  slighter  extent  and  to  a  lesser  depth ;  but,  on  the  other  hand, 
it  undoubtedly  more  frequently  happens  that  the  medullary  swelling 
undergoes  involution  through  absorption  without  disintegration.  The 
mesenteric  glands  are  also,  in  general,  less  markedly  swollen,  and  only 
with  extreme  rarity  are  found  in  a  state  of  softening. 

The  condition  of  the  spleen  exhibits  no  material  difference  from  that 
which  occurs  in  mature  life.  It  may  possibly  be  stated  that  enlarge- 
ment of  the  spleen  at  an  early  period — that  is,  before  the  beginning  or 
the  middle  of  the  second  week  of  the  disease — is  less  common  in 
children  than  in  adults,  and  that  it  does  not  frequently  exceed  moderate 
proportions.  In  my  experience,  actual  persistent  absence  of  splenic 
enlargement  or  of  the  possibility  of  its  demonstration  has  been  rather 
less  common  in  children  than  in  adults. 

Among  affections  of  the  respiratory  organs,  typhoid  bronchitis  does 


334  TYPHOID  FEVER. 

not  differ  with  reference  to  frequency  and  extent  from  that  of  later 
])eriods  of  life.  In  children  also  it  is  one  of  the  nioro  valuable  diag- 
nostic symptoms  of  the  disease.  It  is  associated  rather  frequently 
with  atelectasis  and  lobular  pneumonia,  especially  in  debilitated  children. 
Simple  and  inflammatory  hyjwstasis  of  the  lungs  is,  however,  all  the 
more  rare — a  fact  that  sheds  a  strong  light  upon  the  favorable  state  of 
the  heart-power  in  children  that  has  been  repeatedly  pointed  out.  True 
lobar,  fibrinous  pneumonia  I  have  observed  but  exceptionally  in  chil- 
dren. Pleuritis  and  empyema  also  are,  according  to  the  statements  of 
most  observers  and  my  own  experience,  relatively  uncommon.  The 
same  statement  is  applicable  also  to  affections  of  the  larynx,  both  simple 
ulceration  of  the  mucous  membrane  and  perichondritis  and  necrosis  of 
the  cartilage.  As  has  been  pointed  out  with  regard  to  a  considerable 
number  of  other  conditions,  these  laryngeal  affections  become  somewhat 
more  frequent  again  in  later  childhood. 

The  symptoms  on  the  part  of  the  nervous  system  usually  vary  in 
accordance  with  the  severity  of  the  attack.  In  mild  and  even  moder- 
ately severe  cases  they  are  relatively  slight — generally  far  less  marked 
than  in  adults.  In  the  early  period  the  children  are  ill-tempered, 
irritable,  and  lacrimose ;  they  subsequently  become  dull,  apathetic,  and 
more  or  less  stupid.  The  severe  cases,  however,  sometimes  set  in  with 
convulsions,  and  even  during  their  course,  especially  in  older  children, 
often  exhibit  alarming  symptoms.  Among  these  symptoms,  severe 
headache,  rigidity  of  the  neck  and  back,  general  hyperesthesia,  with 
sluggishness,  dilatation,  and  even  inequality  of  the  pupils,  and  profound 
stupor  progressing  mto  deep  coma,  should  especially  be  mentioned. 
IS^ervous  sequels,  such  as  spinal  affections,  neuritis,  and  cerebral  disturb- 
ances, especially  psychoses,  are,  on  the  other  hand,  comparatively  rare 
in  children.  Neuralgic  disorders  also — for  instance,  the  distressing 
pains  in  the  heels  and  toes  so  frequent  in  adults — have  practically  not 
come  under  my  observation  in  children.  Reference  may  here  be  made 
again  to  the  as  yet  unexplained  transitory  aphasia  (pp.  275  and  276) 
occurring  almost  exclusively  in  childhood,  which,  although  mentioned  by 
earlier  observers,  has  recently  been  again  pointed  out,  particularly  by 
Gerhardt  (Clarus  Diss.)  and  Kiihn. 

With  regard  to  the  condition  of  the  organs  of  special  sense  in  cases 
of  typhoid  fever  in  childhood,  little  is  known,  so  far  as  I  am  informed, 
with  regard  to  the  eyes.  Typhoid  affections  of  the  ear,  both  those  of 
nervous  origin  and  those  associated  with  affections  of  the  nasopharynx 
and  Eustachian  tube,  appear  to  be  not  less  frequent  than  in  adults. 

The  kidneys  are  comparatively  resistant  during  childhood.     Febrile 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  335 

albuminuria  is  distinctly  less  common  at  this  time,  and,  if  present  at 
all,  is  slighter  and  of  shorter  duration.  Actual  nei)hritis  appears  to 
occur  but  exceptionally.  I  have  personally  observed  no  case  of  the 
kind  in  a  child.  The  diazo-reaction  of  Ehrlich  is,  apparently,  almost 
never  absent  in  childhood — a  fact  to  whicli,  in  view  of  the  limitations 
previously  mentioned,  not  inconsiderable  diagnostic  significance  is  to  be 
attached. 

The  duration  of  typhoid  fever  in  childhood  is,  as  has  been  previously 
indicated,  on  the  whole,  shorter  than  in  adults.  Undoubtedly,  the  mild 
and  abortive  cases  are  even  more  common  in  children ;  and  the  well- 
developed  cases  of  severe  onset  generally  terminate  earlier  than  they  do 
in  later  life.  The  abbreviation  affects  all  stages  of  the  disease,  both  the 
febrile  period  and  convalescence.  The  febrile  period  in  well-developed 
cases  is  likely  to  be  shortened  at  times  in  all  its  stages,  while  at  other 
times  only  one  or  another  stage  is  shortened,  especially  that  of  ascending 
temperature  or  that  of  defervescence.  It  is  interesting  that  the  duration 
of  the  fever  in  well-marked  cases  appears  to  be  shorter,  on  the»  whole, 
the  younger  the  child.  In  children  below  the  age  of  six  years  the 
duration  much  less  commonly  exceeds  three  weeks  than  it  does  in  older 
children ;  and  even  in  the  latter,  differences  in  relation  to  age  are  likely 
to  make  themselves  distinctly  manifest  in  the  manner  indicated. 

The  following  table,  based  upon  the  cases  observed  at  Hamburg 
from  1886  to  1887,  is  most  instructive.  Of  443  children  between  the 
ages  of  two  and  fourteen  years,  the  duration  of  the  fever  was : 

2  to  5  years.  6  to  10  years.  10  to  14  years. 

Up  to  21  days 92  per  cent.         71.8  per  cent.         60.8  per  cent. 

Between  22  and  33  davs  .        4       "  18.6       "  25.7      " 

More  than  33  days     .\    .        2       "  1.1       '■'■  11.8      " 

The  shorter  duration  of  the  fever,  the  greater  resistance  to  the  action 
of  the  toxins,  and  the  lesser  frequency  and  severity  of  complications  are 
responsible  for  the  fact  that  convalescence  is  in  general  completed  earlier 
in  children  than  it  is  in  adults.  This  applies  not  only  to  restoration 
of  the  structure  of  the  affected  organs,  but  also  to  restoration  of  the 
former  state  of  nutrition,  especially  a  return  to,  and  not  rarely  even  an 
increase  beyond,  the  former  body-weight.  With  reference  to  the  latter, 
children  exhibit  a  peculiar  relation.  After  severe  and  moderate  attacks 
they  lose  flesh  in  the  febrile  stage  with  comparatively  greater  rapiditv, 
and  in  general  in  somewhat  greater  degree  than  adults,  but  even  in 
the  worst  cases  they  do  not  suffer  the  extreme  loss  of  weight  that 
occurs  in  the  latter.  While  the  greatest  loss  of  weight  that  I  have 
observed  in  severe  cases  in  adults  was  in  one  instance  32  per  cent., 


336  TYPHOID  FEVER. 

9  per  ceut.  was  the  maxinium  encountered  in  children  under  the  age 
of  twelve  years.  On  the  other  hand,  the  niininunu  loss  of  weight 
observed  in  children  with  severe  and  moderately  severe  attacks  was 
2.0  per  cent,  of  the  body-weight,  and  the  least  among  adults  under 
the  same  circumstances  only   1.5  per  cent. 

The  general  rule,  that  relapses  are  likely  to  be  the  more  frequent 
the  younger  the  patient,  is  applicable  also  to  childhood.  The  tendency 
to  recrudescences  and  relapses  is,  without  doubt,  more  pronounced  at 
this  period  of  life  than  in  later  years.  Exceptional  contradictory 
statements  are  based  either  upon  too  small  statistics  or  upon  exceptional 
epidemics  and  endemics,  which,  as  a  matter  of  fact,  may  occasionally 
exliibit  a  deviation  from  the  rule. 

Thus,  in  Hamburg,  in  the  year  1887,  although  I  observed  not  actually 
fewer  relapses  in  children,  the  percentage  of  relapses  was,  nevertheless, 
disproportionately  lower  than  in  adults  ;  while  the  figures  for  the  year  1886, 
and  those  for  fourteen  years  at  Leipsic,  agree  with  those  that  I  believe  to 
represent  the  usual  state  of  affairs.  There  occurred  in  Hambui'g  in  1886  : 
Relapses  in  adults  in  13.4  per  cent.  ;  in  children  in  19.5  per  cent.  ;  in  Leip- 
sic, relapses  in  adults  in  12.5  per  cent.  ;  in  children  in  19.1  per  cent. 

It  is  interesting  that  even  in  relapses  in  children  the  preponderant 
occurrence  in  the  female  sex — which  almost  constantly  occurs  in  adults — 
is  at  times  distinctly  exhibited,  as  the  following  statistics  of  Hamburg  show : 

Boys. 

Eelapses,  1886 15.5  per  cent. 

Relapses,  1887 11.9         " 

A  fatal  termination  of  the  disease  in  childhood  is,  in  general,  less 
frequent  than  m  adults,  as  is  almost  obvious  from  all  the  foregoing 
observations. 

All  estimates  based  upon  large  statistics  confirm  this.  In  Hamburg, 
for  instance,  the  mortality  among  adults  in  the  year  1886  was  11.5  per 
cent.  ;  that  among  children,  7.3  per  cent.  In  the  year  1887  the  mortality 
among  children  was  6.8  per  cent.,  with  an  average  mortality  later  in  life 
of  8.8  per  cent. 

If  these  conditions  are  scrutinized  somewhat  more  carefully,  the 
remarkable  fact  will  become  apparent  that  this  low  mortality  applies 
especially  to  children  up  to  the  tenth  year.  From  the  tenth  to  the 
fourteenth  year  the  mortality  approximates  that  of  the  next  age-period 
— from  fifteen  to  twenty. 

A  tabulation  of  the  related  figures  from  Hamburg  shows :  Between  the 
second  and  the  fifth  years,  a  mortality  of  4  per  cent.  ;  sixth  and  the  tenth 
years,  6.4  per  cent.  ;  eleventh  and  the  fourteenth  years,  8.1  per  cent.  ; 
fifteenth  and  the  twentieth  years,  8.7  per  cent. 

In  infants,  and  in  general  during  the  first  two  years  of  life,  up  to 


Girls. 

Total. 

23.8  per  cent. 

19.1  per  cent. 

15.0 

13.4 

VARIATIONS  IN  SYMPTOMS  AND  COURSE.  337 

the  third,  typhoid  fever  appears  to  be  distinctly  less  common  than  in 
later  childhood.  It  is  true,  as  has  been  seen,  that  intra-utermc  trans- 
mission may  take  place,  although  this,  in  relation  to  the  number  of 
typhoid  mothers,  is  to  be  considered  as  most  exceptional,  and  is  depend- 
ent upon  certain  definite  conditions.  I  have  often  seen  infants  and 
children  between  one  and  two  years  old  remain  healthy,  in  spite  of  con- 
stant and  intimate  association  with  a  typhoid  mother.  A  final  opinion 
as  to  the  relative  frequency  of  the  disease  in  the  earliest  years  and  in 
later  childhood  is,  naturally,  not  to  be  formed  from  ordinary  statistical 
data.  The  picture  of  moderate  and  mild  attacks  in  infants  is  so  entirely 
uncertain  and  ill-defined  that  more  cases  are  certainly  overlooked  at 
this  period  than  in  later  childhood. 

Conclusions  based  upon  large  statistics  may  be  reached  from  the  reports 
of  the  Elizabeth  and  Oldenburg  Children's  Hospitals  of  St.  Petersburg. 
In  the  former  there  were,  from  the  year  1844  to  1896,  3504  cases  of  typhoid 
fever  among  352,370  children  treated  in  the  dispensary.  These  cases  are 
divisible  according  to  age  as  follows  : 

1-6  Months.  6-12  Months.  1-2  Years.  2-5  Years.  Over  five  years. 

9— 0.26perct.   35— 0.99  per ct.   173— 4.94  per  ct.   1481— 42.3  per  ct.   1806— 51. 3 per  ct. 

In  the  outpatient  service  of  Rauchfuss  at  the  Oldenburg  Children's 
Hospital  there  were,  among  77,073  sick  children,  647  with  typhoid  fever, 
of  the  following  ages  : 

1-6  Months.  6-12  Months.  1-2  Years.  2-6  Years.  Over  six  years. 

2-_0.31  per  ct.     5— 0.77  per  ct.     14— 2.15  per  ct.    213  -32.9  per  ct.    413— 63.8  per  ct. 

Ollivier^  had  among  611  cases  of  typhoid  fever  in  children  only  3 
under  the  age  of  two  years.  My  own  3  patients  were  nine  and  eleven 
months  and  one  and  three-quarter  years  old  respectively. 

The  clinical  statements  that  have  hitherto  been  made  with  regard  to 
typhoid  fever  in  infants  are  based  especially  upon  severe  well-developed 
cases.  Also,  my  3  cases  of  that  character,  the  only  certain  ones  that 
I  have  seen,  pursued  a  severe  course,  1  terminating  fatally.  Mod- 
erately severe  and  mild  cases  have  been  reported  but  exceptionally. 
Among  these  belongs  the  well-known  observation  of  Gerhardt^  of  a 
case  of  typhoid  fever  in  a  child  three  weeks  old,  probably  infected 
within  the  uterus  from  the  mother. 

The  beginning  of  the  attack  of  typhoid  fever  in  young  children 
can  but  rarely  be  determined  even  in  well-marked  cases,  probably  even 
less  commonly  than  during  the  subsequent  years  of  life.     Only  excep- 

^  Lecons  din.  sur  les  mal.  de  Venfance. 

^  Handb.  d.  Kinder krankh..,  Bd.  ii.     In  this  book  the  earlier  literature  of  typhoid 
fever  in  infancy  has  been  carefully  collected. 
22 


338 


TYPHOID  FEVER. 


tionally  in  young  children  does  the  disease  api)ear  to  set  in  abruptly 
and  the  fever  to  rise  rapidly.  When  it  has  l)een  possible  to  observe 
the  initial  stage,  the  eurve  generally  was  step-like,  indeed  somewhat 


Day  of  the  disease. 


5         B          7         a         9         10        11         12       13         I'l-       15        IS        17        18        19 

FF  111'     III'     'Ml     1.1  1  1    11  11     'MI  TTT  11  1  1     MM     MM    MM  M  III    1  ILL  MM     nil 

r. 

180 

1.     :::: ::_:p:_" —                         ±1"                                  ± 

'ii   :"_":"":":::::::_           *'+  _            -        _  - 

_-  ^ 

160 

liQ         -X-,2\        ^        ^    t     .           'ji^.                          Jl 

t?    rvv^T  *  ."f    »             ^                                                  ' 

T)0 

X  i      -:      /:./ I-':, /!,___  K^ L.     --^"-^"     :       -   ""      :          :  :::::-:---"- 

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39             ->ii  -    i-C^iX:7    _J1V    iMvI      X/LC      ~V- 

--     'sr-'^^s-":       1*    If.      1    rv     \                                                      -         -   -- 

120 

■  ;       r          s._t"J       I'                                     — 

3^       :l     -j_r3tt,zj:  I    :                                        ^^       ' 

38          -                            tl     /       ^^    ^     n        ^        5,''^..        ^      s'^          ;-- 

'^                             .   ;i--i ^ r-^----^- -  -.;:=>,< -   -L-  :'     " 

100 

:       ;         _           L       L  z                >                     — ^7 

:                 3     Kv              J                 '     "  s^"~ 

-_;_        -;                        -.         _         1                                   ?.                      it:        ---ir'         -- 

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jii+..4:j+ :_..: ::.,!:i:::,i:i..:.L_l:i:_.^±:\i5,,i.: 

80 

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_    X                   _                 .                                                    -  -V         -          -            *- -    -^ -- - 

36                 -                                                                                                            i 

60 

35 :__:+::::::::::::::::::::_::_::::::::::: 

Fig.  33. 


shortened,  as  in  Gerhardt's  case.  Also  the  fastigium,  and  with  it  the 
entire  febrile  period,  appears  to  be  generally  of  relatively  short  duration, 
although  exceptional  cases  have  been  observed  that  were  }>rotracted  for 


Day  of  the  disease. 

3     ^     5     6 

7    8    9    10  n 

]2    13   n    15   16   17    18   19  20  21   22  23  24   25  26 

'T                                                   '' 

] 

f 

1 

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1 

1 

h^ 

f 

! 

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1                            <A 

Ijlt 

l.r,         -j''^            / 

TjA    a       I+I  J 

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^\                                 ^            J^                  t    H                      /  

38 

i_i        J        L.^    .    »4_z     .,'.,- 

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T±          I        5^^^      "1         .2^_-,2-^ 

m^Z                              it*          k!    fi     fe-  - 

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T-                           k 

-^-                                *                              V 

37 

,        ' 

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, 

1      1 

, 

I        36 

Fig.  34. 


as  long  as  twenty-seven  and  even  thirty-one  days  before  defervescence 
occurred  (Filatow  ^).     It  is  noteworthy  that  in  severe  cases  of  typhoid 

^  Vorlesungen  uher  Acute  Tnfektionskrankheiten  im  Kindesalter.     Translated  into 
German  from  the  second  Kussian  edition,  Vienna,   1897. 


VARIATIONS  IN  SYMPTOMS  AND   COURSE.  339 

fever  in  infancy  the  temperature  is  quite  high  at  the  fastigium,  in  gen- 
eral higher  than  during  the  succeeding  years,  and  the  temperature-curve 
is  likely  to  resemble  that  of  remittent  continued  fever.  In  the  period 
of  defervescence  the  type  of  steep  curves  not  rarely  makes  itself  mani- 
fest also  in  infants.  As  an  illustration,  I  present  the  curve  from  a  child 
one  and  three-quarter  years  old  under  my  care  (Fig.  33),  and  one  from 
a  little  patient  of  Filatow's  (Fig.  34)  eight  months  old. 

The  pulse  is,  as  would  be  anticipated,  remarkal)ly  frequent  and 
variable  in  cases  of  typhoid  fever  in  infancy,  without  the  number  cjf 
pulse-beats  being  in  itself  of  especial  prognostic  significance.  Enlarge- 
ment of  the  spleen  is  generally,  although  not  constantly,  demonstrable ; 
but,  on  account  of  the  frequency  of  its  occurrence  in  connection  with 
all  possible  conditions  during  early  childhood,  it  is  in  itself  of  much  less 
diagnostic  importance  than  in  later  years.  EoscoIjb  appear  to  be  gener- 
ally few  in  number,  and  are  oftener  wholly  absent  in  young  children 
than  in  older  ones.  In  one  of  my  cases — in  a  child  eleven  months  old — 
which  was  under  clinical  observation  from  the  very  beginning  until  its 
fatal  termination,  and  was  examined  anatomically  after  death,  roseolas 
were  at  no  time  demonstrable.  Exceptionally,  however,  they  have  been 
found  in  great  profusion,  as,  for  instance,  in  Gerhardt's  case. 

Thin,  watery  stools  appear  to  be  quite  frequent — more  constantly  so 
than  in  older  children.  The  daily  number  of  stools  is  at  the  same  time 
comparatively  small,  and  this  fact  may  be  a  guide  in  the  differentiation 
from  other  conditions  of  early  childhood  which  are  attended  with  diar- 
rhea. The  meteorism  is  said  by  almost  all  observers  to  be  slight.  One 
of  my  cases — in  a  cliild  eight  months  old — in  which  recovery  ensued,  at 
one  time  throughout  the  entire  course  of  the  disease  exhibited  distention 
of  the  abdomen. 

Vomiting  is  particularly  frequent  in  the  mitial  stage  and  at  its 
inception.  Also,  during  the  further  course  of  the  disease  it  is  often 
repeated.  In  association  with  the  rigidity  of  the  neck  and  back,  which 
is  not  rarely  present  from  the  beginning  of  the  fever,  the  crying,  and  the 
twitching,  increasing  to  the  point  of  convulsions,  it  is  well  calculated  to 
excite  suspicion  of  meningitis,  which  is  the  disease  most  frequently  con- 
founded with  typhoid  fever  in  early  childhood.  With  the  progress  of 
the  fever,  and  at  the  fastigium,  these  symptoms  usually  subside,  to  be 
replaced  by  more  or  less  marked  stupor  and  sopor. 

Bronchitis  appears  in  general  to  be  mild  in  infants,  while  lobular 
pneumonia  is  particularly  frequent,  and  is  one  of  the  common  direct 
causes  of  death. 

The  duration  and  prognosis  of  well-marked  typhoid  fever  in  infants  - 


340  TYPHOID  FEVER. 

are  distinctly  unfavorable  in  comparison  with  those  of  the  succeeding 
years,  and  arc  the  trraver,  apparently,  the  yountrer  tlie  child.  Marfan^ 
estimates  the  mortality  in  early  childhood  at  50  per  cent.  In  addition 
to  bronchopneumonia  and  severe  toxcuiia,  which  are  by  far  the  most 
frequent  causes  of  death,  jicrforation  of  the  bowel  (Drewit)  and  ulcera- 
tion of  the  larynx  (Lewy)  exceptionally  act  as  direct  causes  of  death, 
even  in  the  younsi:est  children. 

Typhoid  Fever  in  Later  Life. — Xa  early  as  the  fortietli  year  of 
life  the  slighter  susceptibility  to  the  disease  becomes  apparent.  The 
predisjiositiou  still  further  diminishes  after  the  fiftieth  year,  so  that 
typhoid  fever  in  old  age  may  really  be  designated  as  a  rare  occurrence. 

Among  5306  cases  of  typhoid  fever  observed  at  Leipsic  and  Hamburg,  I 
found  177  between  forty  and  fifty  years  of  age  ;  41  between  fifty  and  sixty  ; 
14  between  sixty  and  seventy  ;  and  5  over  seventy.  There  were  1885 
between  the  ages  of  fifteen  and  twenty-five  years,  however. 

The  influence  of  later  life  with  reference  to  the  course  and  the 
prognosis  of  the  disease  is  exceedingly  unfavorable.  As  early  as  the 
second  half  of  the  fourth  decade  the  disease  in  its  general  course,  or  in 
relation  to  special  features,  is  likely  to  assume  a  serious  and  even  an 
alarming  character.  Above  the  fortieth  year  the  mortality  increases 
enormously,  so  that  in  the  years  between  fifty  and  sixty  it  reaches 
from  three  to  five  times  that  between  fifteen  and  tAventy-five. 

The  mortality  in  Hamburg  in  1886-1887  was,  in  the  age-period  from 
twenty-one  to  twenty-five,  7.7  per  cent.  ;  twenty-six  to  thirty,  12.3  per  cent.  ; 
thirty-one  to  thirty-five,  11.5  per  cent.  ;  thirty-six  to  forty,  14.9  per  cent.  ; 
forty-one  to  forty-five,  18.5  per  cent.  ;  forty-six  to  fifty,  26.1  per  cent.  ;  fifty- 
one  to  fifty-five,  23  per  cent.  ;  fifty-six  to  sixty,  37.5  per  cent. 

The  statistics  of  the  clinic  at  Leipsic  (1880-1893),  with,  it  is  true, 
a  higher  average  mortality,  disclose  similar  relations.  The  mortality  was, 
in  the  age-period  from  twenty  to  twenty -four,  13.8  per  cent.  ;  twenty-five 
to  twenty-nine,  12  percent.;  thirty  to  thirty -four,  15  percent.;  thirty-five 
to  thirty-nine,  28.3  per  cent.  ;  forty  to  forty-four,  29.2  per  cent.  ;  forty-five 
to  forty-nine,  31  per  cent.  ;  fifty  to  fifty-nine,  40  per  cent. 

In  the  majority  of  cases  in  senile  individuals  the  beginning  of  the 
attack  and  the  ascent  of  the  fever  are  gradual.  When  the  beginning  of 
the  febrile  period  is  attended  with  chilly  sensations,  these  are  likely  to 
consist  generally  in  repeated  chilliness,  only  quite  rarely  confined  to  a 
single  chill ;  in  the  latter  case  the  course  is  usually  abnormal  in  other 
respects  also. 

The  further  evolution  of  the  entire  clinical  picture  is  marked  by 
the  evidences  of  lessened  powers  of  resistance  of  the  senile  body  to  the 

*  Traite  des  maladies  de  Venfance,  1897.  This  work  contains  also  numerous 
bibliographic  references,  especially  to  recent  French  publications. 


VARIATIONS  IN  SYMPTOMS  AND  COURSE.  341 

intoxication.  In  marked  contrast  to  the  period  of  youth,  this  lowered 
resistance  is  frequently  exhibited  in  the  general  condition,  and  particu- 
larly in  the  condition  of  the  nervous  system.  Great  prostration  is 
present  from  the  beginning.  Among  the  special  nervous  disturbances, 
symptoms  of  excitement  are  much  less  frequent  than  those  of  depression. 
The  patients  become  stuj)id  at  an  early  period.  Not  rarely  they  are 
profoundly  soporose  or  deeply  comatose  at  the  beginning  of  the  second 
week.  At  the  same  time,  or  a  little  later,  great  asthenia,  accompanied 
by  tremor,  subsultus  tendinum,  and  floctitation,  sets  in.  The  patients 
under  such  circumstances  are  restless,  often  wholly  sleepless,  but  gener- 
ally without  severe  delirium.  Pallid,  with  relaxed  features  and  half- 
open  eyes,  murmuring  feebly  to  themselves,  they  occupy  a  relaxed  dorsal 
decubitus,  the  picture  of  the  adynamic  febrile  course  of  earlier  writers. 

This  character  of  relaxation  or  adynamia  is  exhibited  in  the  course 
of  the  fatal  cases,  as  well  as  in  that  of  the  severe  cases  that  eventually 
terminate  in  recovery.  The  latter  are  generally  unusually  long  in  dura- 
tion, not  alone  with  reference  to  the  febrile  stage,  but  in  comparatively 
still  greater  degree  with  reference  to  the  stage  of  convalescence.  The 
fever,  under  such  circumstances,  does  not,  in  the  majority  of  cases, 
attain  the  same  height  as  is  likely  to  be  attained  in  severe  cases  during 
adolescence.  On  the  contrary,  the  temperature-curve  is  very  frequently 
observed  to  pursue  a  relatively  low  level,  just  as  the  afebrile  cases  of 
most  severe  course,  as  was  previously  mentioned,  prmcipally  occur  in 
debilitated  senile  individuals.  In  addition,  the  form  of  the  curve  is 
far  more  frequently  irregular,  markedly  remittent,  at  times  intermittent, 
and  marked  by  attacks  of  true  or  false  collapse  than  occurs  at  any  other 
time  in  life.  Often  the  stages  of  the  disease  are  imperfectly,  if  at  all, 
marked  in  the  temperature-curve,  so  that  neither  the  step-like  ascent  at 
the  beginning,  nor  the  continuance  of  a  considerable  average  elevation 
of  temperature  in  the  severest  period  of  the  disease,  nor  yet  a  marked 
stage  of  steep  curves,  is  present.  Not  a  few  cases,  on  the  contrary, 
pursue  so  anomalous  a  course  that  the  form  of  the  curve  furnishes 
no  diagnostic  information  whatever,  but  rather  may  lead  to  incorrect 
conclusions. 

The  slowing  of  the  pulse,  which  is  so  frequent  and  characteristic  in 
young  vigorous  individuals,  is  extremely  rare  in  the  aged,  and  in  my 
experience  almost  only  occurs  when  the  senile  character  of  the  disease 
is  also  less  marked  in  other  respects.  The  pulse  in  elderlv  mdividuals 
is,  on  the  contrary,  usually  frequent  from  the  outset — on  the  average 
more  so  than  the  height  of  the  temperature  warrants ;  and,  what  is 
indicative  especially  of  a  marked  toxic  effect  upon  the  heart  and  the 


342  TYPHOID  FEVER. 

vasomotors,  is  the  fact  that  the  pulse  is  early  of  low  tension,  irreonlar, 
and,  M'heu  arteriosclerosis  is  not  present,  is  soft,  hut  sekloni  dicrotic. 

The  cardiac  weakness  that  so  early  appears  in  the  foreground  is  also 
responsible  in  considerable  degree  for  the  state  of  tlie  respiratory  organs. 
On  account  of  the  impaired  propulsive  j)ower  of  the  right  side  of  the 
heart,  the  typhoid  -  bronchitis  early  attains  a  considerable  degree  of 
intensity  and  extent.  The  associated  hypostatic  congestion  which,  in 
comparison  with  its  frequency  in  early,  life,  very  commonly  occurs  in 
elderly  persons,  is  de])cndent  upon  the  same  cause.  The  onset  of  this 
hypostatic  congestion  constitutes  one  of  the  indications  of  a  fatal  out- 
come in  senile  tj'phoid  fever.  The  occurrence  of  bronchopneumonia  is 
associated  with  the  prevalence  of  bronchitis,  and  occurs  with  almost 
equal  frequency  in  childhood  and  in  later  life.  Elderly  patients  suffer- 
ing from  typhoid  fever  are  not  less  frequently  attacked  by  croupous 
pneumonia  than  younger  patients,  wliile  pneumonia  due  to  streptococci 
a]>pcars  to  me  to  occur  more  frequently  in  the  former.  The  greater 
tendency  to  gangrene  and  abscess  in  association  with  pneumonia  in  older 
patients  is  noteworthy.  That  the  chronic  bronchial  and  pulmonary  aifec- 
tions  often  existing  in  old  persons  before  the  development  of  the  typhoid 
fever  give  to  this  disease  a  grave  aspect  needs  scarcely  be  esj)ecially 
pointed  out. 

The  anatomic  and  clinical  manifestations  on  the  part  of  the  intes- 
tinal canal  exhibit  no  radical  differences  from  those  in  other  adults.  This 
is  applicable  especially  to  the  number  and  the  character  of  the  stools. 
The  meteorism,  which  not  rarely  is  marked,  sets  in  relatively  early.  In 
contradistinction  to  the  conditions  in  childhood,  elderly  individuals — 
and  this  applies  especially  to  the  period  between  the  thirty-fifth  and  the 
fortieth  years — exhibit  a  somewhat  greater  tendency  to  intestinal  hemor- 
rhage. Elderly  persons  also  succumb  more  readily  to  this  accident. 
Even  slight  hemorrhages  that  would  exert  scarcely  any,  or  but  a  transi- 
tory', influence  upon  younger  persons,  constitute  a  source  of  considerable 
danger  for  older  ones.  Perforative  peritonitis  appears  to  me  to  be,  on 
the  whole,  by  no  means  more  frequent  in  advanced  life,  but  rather  less 
common  than  during  adolescence. 

The  increased  difficulty  in  the  diagnosis  of  typhoid  fever  in  elderly 
persons,  in  consequence  of  the  variability  and  irregularity  in  the  fever- 
curv^e,  is  still  further  augmented  by  the  state  of  the  spleen  and  the 
roseolas.  Enlargement  of  the  spleen  in  elderly  persons  is,  on  the  whole, 
distinctly  less  common  than  at  other  periods  of  life.  In  none  of  these 
earlier  periods  have  I  observed  total  absence  throughout  the  entire 
course  of  the  disease  nearly  so  frequently  as  during  the  later  periods  of 


VARIATIONS  IN  SYMPTOMS  AND  COUESE.  343 

life.  Experience  at  the  autopsy-table  affords  a(lc({uate  explanation 
for  this.  The  involution  of  the  organ  associated  with  advanced  life, 
antecedent  disease  of  the  spleen  and  its  capsule,  extensive  or  multiple 
cicatrices  resulting  from  infarcts,  diffuse  connective-tissue  hyperplasia, 
and  perisplenitic  thickening  of  the  capsule  are  all  to  be  mentioned  espe- 
cially as  factors  which  explain  the  infrequency  of  splenic  enlargement. 
If  these  prevent  the  occurrence  of  enlargement  of  the  spleen  in  a  por- 
tion of  the  cases,  the  difficulty  in  the  demonstration  of  the  enlargement, 
even  when  it  exists,  is  still  further  increased  by  displacements  and  adhe- 
sions, dependent  upon  disease  at  an  earlier  period  in  life,  which  naturally 
are  more  common  in  older  individuals.  Also,  the  rare  cases  in  which, 
at  the  height  of  the  disease,  I  have  observed  anatomically  entire  inex- 
plicable absence  of  enlargement  of  the  spleen,  occurred  almost  solely  in 
elderly  persons. 

While  the  typhoid  roseolce  do  not,  in  my  experience,  occur  less  com- 
monly in  advanced  life,  the  eruption  is,  on  the  whole,  less  profuse,  and 
often  extends  over  a  shorter  period  of  time.  In  addition,  the  indi- 
vidual roseolse  are,  in  general,  smaller,  less  bright  in  color,  and  of 
shorter  duration — peculiarities  that  are  apparently  associated  with  the 
senile  alterations  in  the  skin.  The  same  explanation  probably  also 
holds  for  the  less  common  appearance  of  sudamina,  and,  conversely,  for 
the  greater  tendency  to  bed-sores. 

With  regard  to  the  changes  in  the  kidneys,  typhoid  nephritis  appears 
to  me  to  be  distinctly  less  frequent ;  while  the  occurrence  and  the 
symptomatology  of  febrile  albuminuria  exhibit  no  differences  from  those 
of  the  same  condition  at  other  times  of  life. 

With  reference  to  typhoid  fever  in  the  aged  in  general,  it  should  be 
emphasized  that  in  the  event  of  recovery  it  has  the  most  frequently,  of 
all  the  varieties,  a  long-drawn-out  and  protracted  course.  Severe  com- 
plications are  not  numerous  or  diverse,  for  the  simple  reason  that  aged 
persons  almost  always  succumb  to  the  first  that  appears.  Of  the  special 
varieties  of  the  disease  previously  mentioned,  the  hyperpyretic  and  the 
hemorrhagic  forms  are  distinctly  less  common  in  later  life.  The  pre- 
ponderant early  involvement  of  particular  organs,  giving  the  disease  a 
special  character,  appears  also  to  be  less  frequent.  Cases  that  could  be 
designated  nephrotyphoid,  meningotyphoid,  or  pleurotyphoid  have  in 
my  experience  but  rarely  occurred  in  older  persons.  Pneumot^^Dhoid, 
however,  appears  to  me  to  be  not  less  common  than  dm-ing  adolescence. 

With  reference  to  relapses  and  recrudescences,  it  is  noteworthy  that 
their  frequency  diminishes  distinctly  w^ith  increasing  years,  but  their 
prognosis  is  far  more  grave  than  in  younger  individuals.     That  death 


344  TYPHOID  FEVER. 

occurs  at  a  comparatively  early  period  is  in  no  small  degree  due  to  the 
lessened  bodily  resistance.  But,  on  the  other  hand,  death  may  often 
occur  in  elderly  individuals  after  attacks  M'hich  were  in  themselves 
apparently  not  severe,  but  which  were  of  unusually  long  duration. 
The  impression  is  gained  that  such  patients  are  no  longer  able  to  resist. 
The  incom])lete,  mild,  or  abbreviated  attack — mild  typhoid  fever,  abor- 
tive typhoid  fever,  etc. — doubtless  occurs  also  in  advanced  life.  The 
exact  relation  its  frequency  bears  to  that  during  earlier  periods  of  life  is 
unknown  to  me,  and,  so  far  as  I  am  aware,  has  not  yet  been  determined. 

RECRUDESCENCES  AND   RELAPSES. 

In  cases  of  typhoid  fever  of  any  variety  or  course  it  may  happen 
that  before  the  onset  of  final  convalescence  there  may  occur,  without 
any  other  general  or  visceral  disease,  once  or  even  several  tunes, 
febrile  states  whose  course  and  associated  phenomena  may  more  or  less 
closely  resemble  those  of  the  primary  febrile  period.  They  are  desig- 
nated, for  obvious  reasons,  as  relapses,  if  the  first  period  of  the  disease 
is  separated  from  the  renewed  elevation  of  temperature  by  a  completely 
afebrile  interval,  and  as  recrudescences,  if  the  reascent  occurs  during 
the  period  of  involution,  before  the  declining  temperature  has  com- 
pletely returned  to  the  normal. 

Clinically  and  anatomically,  relapses  and  recrudescences  represent 
recurrences,  in  more  or  less  complete  degree,  of  the  typhoid  morbid 
process.  As  to  the  question  whether  they  are  to  be  attributed  to 
renewed  infection  or  to  a  revival  of  the  primary  process,  it  may  be  said 
that  at  the  present  time  it  has  been  definitely  settled  that  they  arise  in 
the  latter  manner.  Undoubtedly,  their  development  is  to  be  attributed 
to  the  re-entrance  into  the  circulation  of  living  typhoid-bacilli  which, 
after  the  primary  attack,  were  left  behind  in  various  organs ;  and  asso- 
ciated with  this  more  or  less  complete  redevelopment  of  the  local  and 
general  typhoid  lesions  occurs.  The  patients  then  again  exhibit  fever, 
often  in  a  most  characteristic  manner,  with  re-enlargement  of  the  spleen, 
roseolse,  meteorism,  and  diarrhea,  and,  in  fatal  cases  in  which  post- 
mortem examinations  are  made,  newly  developed  specific  intestinal 
lesions,  especially  recent  infiltration  of  Peyer's  patches,  are  found  in 
addition  to  the  healed  lesions. 

As  little  of  a  definite  nature  is  as  yet  Icnown  with  reference  to  the 
manner  in  which  the  typhoid  virus  is  retained  and  the  organs  that  are 
especially  to  be  taken  into  consideration  in  this  connection,  as  with 
regard  to  the  manner  and  the  special  conditions  under  which  the  bacilli 


RECRUDESCENCES  AND  RELAPSES.  345 

again  gain  entrance  into  the  blood.  Probably  the  spleen,  together  with 
the  lymph-glands  and  bone-marrow,  and  possibly  also  the  gall-bladder, 
play  an  important  role  m  this  connection  (see  p.  207). 

From  the  course,  and  especially  the  severity,  (jf  the  primary  disease, 
no  conclusion  can  be  drawn  as  to  the  probability  of  the  occurrence  of  a 
relapse.  Apparently,  the  predisposition  to  relapse  is  even  greater  in 
the  milder  than  in  the  severer  cases.  In  my  experience,  only  from  25 
to  35  per  cent,  of  relapses  occur  after  severe  primary  attacks,  while  all 
others  follow  moderate  and  mild  attacks.  It  is  quite  common  for 
atypical  cases  of  typhoid  fever — the  mildest,  abortive,  or  ambulatory — 
to  be  followed  by  severe,  long-continued,  and  well-developed  relapses, 
so  characteristic  that  the  previously  uncertaiu  diagnosis  is  first  made 
positive  by  them  (see  Fig.  36). 

Our  Leipsic  statistics  show  that  of  210  relapses,  75  per  cent,  occurred  after 
moderate  and  mild  attacks.  Also,  Ziemssen  observed  among  108  relapses, 
only  28,  thus  about  one-quarter,  following  severe  attacks.  Goth  arrived  at 
similar  results.  That  this  relation  may  be  altered  at  times  in  some  epi- 
demics is  shown  by  my  Hamburg  statistics,  according  to  which  236  relapses 
were  observed  after  severe,  and  260  after  mild,  primary  attacks. 

It  has  been  seen  that  for  the  recognition  of  a  relapse  in  the  strict 
sense  of  the  word  an  actual  afebrile  period  must  have  intervened  between 
the  termination  of  the  primary  attack  and  the  beginning  of  the  secondary 
elevation  of  temperature.  Naturally,  this  interval  is  not  necessarily 
measured  by  days.  Undoubtedly,  from  twelve  to  twenty-four  hours 
may  even  suffice,  and  therefore  it  is  quite  obvious  that  there  exists  only 
a  gradual  transition,  and  no  essential  difference  between  that  which  is 
designated  as  a  recrudescence  and  that  which  is  designated  as  a  relapse. 

The  time  that  elapses  between  the  primary  attack  and  the  beginning 
of  the  relapse  is  extremely  variable.  No  relation  between  the  duration 
of  this  interval  and  the  character  and  severity  of  the  primary  attack 
can  be  demonstrated.  In  my  experience,  which  coincides  with  that  of 
most  observers,  the  largest  number  of  relapses  occurs  before  the  fourteenth 
to  seventeenth  day  after  the  primary  defervescence.  Withia  this  limit 
the  duration  of  the  afebrile  period  is  quite  variable.  The  beginning  of 
the  relapse  is  likely  to  be  somewhat  less  common  during  the  first  few 
afebrile  days,  while  after  the  third  or  the  fourth  day  the  onset  is 
observed  almost  as  frequently  as  on  the  subsequent  days.  About  10  to 
12  per  cent,  of  relapses  begin  after  the  seventeenth  day,  and  the 
majority  of  these  occur  before  the  thirtieth  day.  Even  after  this 
interval,  however,  relapses  may  exceptionally  occur.  The  longest 
time  that  I  have  observed  to  elapse  before  the  onset  of  the  relapse 
was  fifty-three  days. 


346  TYPHOID  FEVER. 

Before  considering  the  clinical  symptoms  of  relapses  and  recrudes- 
cences in  detaU,  it  may  be  stated  in  general  that  with  regard  to  course, 
duration,  and  severity,  they  vary  ahuost  as  much  as  does  the  primary 
attack.  It  has  been  seen  that  the  latter  is,  in  the  large  majority  of 
cases,  unattended  with  slight  or  no  manifestations  durmg  the  period  of 
incubation.  With  ■  this  fact  corresponds  the  common  view  that  the 
afebrile  interval  up  to  the  beginning  of  the  relapse  is  generally  free  from 
any  symptoms  that  might  point  to  the  impending  condition.  To  this, 
however,  there  are  some  exceptions  which  are  of  diagnostic  importance. 

Attention  was  called  some  time  ago  by  Gerhardt  ^  to  one  fact  that 
I  can  completely  verify — that  is,  the  incomplete  subsidence  of  the 
enlargement  of  the  spleen  after  the  primary  defervescence.  So  long  as 
the  enlargement  of  the  spleen  has  not  disappeared,  the  physician  is  not 
relieved  from  anxiety  with  regard  to  a  relapse.  In  the  overwhelming 
majority  of  such  cases  he  wUl,  on  the  contrary,  observe  its  occurrence.  I 
believe  also,  however,  that  careful  attention  should  be  given  to  the  state 
of  the  temperature  and  the  pulse  during  convalescence  with  regard  to 
the  same  point.  I  have  pointed  out  that  after  all  severe  and  moder- 
ately severe,  not  rarely  after  even  apparently  mild,  cases,  the  tempera- 
ture foils  soon  after  defervescence,  not  only  to  the  previously  normal 
level  for  the  individual,  but  for  a  certain  time  even  below  this,  ^ye\\- 
marked  cases  in  which,  after  defervescence,  the  course  of  the  curve 
does  not  become  subnormal  are  not  to  be  considered  as  concluded,  but, 
on  the  contrary,  the  possibility  of  an  impendmg  relapse  should  be 
suspected ;  and  the  suspicion  should  be  stronger  if  the  temperature  at 
this  low  level  exhibits  causeless,  abnormally  marked,  daily  fluctuations. 

This  premonitory  character  of  the  temperature  in  the  face  of  an 
impending  relapse  is  almost  always  associated  with  a  similar  peculiarity 
of  the  pulse.  It  is  likely  under  such  circumstances,  in  spite  of  per- 
fectly quiet,  careful  behavior  on  the  part  of  the  patient,  to  exhibit,  in 
addition  to  relatively  great  frequency,  more  frequent  and  unusually 
marked   fluctuations. 

If  a  large  number  of  curves  from  cases  of  relapse  are  analyzed,  it 
will  be  observed — as  appears  to  me  not  to  have  been  sufficiently  empha- 
sized heretofore — that  in  the  majority  this  peculiar  premonitory  char- 
acter of  the  pulse-curve,  which  is  analogous  to  that  of  the  temperature- 
curve.  Is  present  in  more  or  less  distinctly  marked  degree.  Even 
the  cases  in  which,  in  spite  of  a  subnormal  course  of  the  temperature 
after  the  primary  deferv-escence,  relapse  occurs,  the  onset  is  frequently 
preceded  by  the  important  diagnostic  character  of  the  pulse  mentioned. 

1  Deutsch.  Arch.f.  klin.  Med.,  Bd.  xii. 


RECRUDESCENCES  AND  RELAPSES. 


347 


348 


TYPHOID  FEVER. 


RECRUDESCENCES  AND  RELAPSES. 


349 


If  this  be  compared  with  tlie  rather  rare  cases  in  which  it  was  possible 
to  make  observations  of  the  pulse  as  early  as  the  period  of  incubation,  a 
striking  coincidence  of  the  pulse-tracing  before  the  beginning  of  the 
primary  attack  with  that  preceding  the  relapse  will  be  disclosed. 
There  will  also  be  found  a  resemblance  between  the  relapse  and  the 
primary  attack,  manifested  in  the  temperature-curve,^  and  in  many 
other  features  besides. 

An  instructive  instance  of  a  mild  relapse  with  the  characteristic 
features  of  pulse  and  temperature  just  discussed  is  afforded  by  Fig.  35. 

With  regard  to  the  state  of  the  temperature  during  the  febrile  period 

Day  of  the  disease. 


39  ijO  W  '12  t^'i,  Hii  45  m  H7  tS  49  50  E 

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Fig.  37.— Temperature-chart  from  a  moderately  severe,  protracted  case  of  typhoid  fever  in  a 
servant-girl  nineteen  years  old.  A  relapse  set  in  on  the  forty-first  day  of  the  disease,  with  step- 
like ascent  of  the  temperature. 

of  the  recrudescence  and  the  relapse,  both  the  duration  of  its  elevation 
and  the  character  of  the  curve  are  extremely  variable,  just  as  in  the 
primary  attack.  Kelapses  may  occur  with  fever-periods  of  from  eighteen 
to  twenty  days,  and  even  longer.  They  not  rarely  exhibit  (Fig.  36) 
almost  exactly  the  same  course  as  moderately  severe  or  mild,  typical 
attacks  of  typhoid  fever.^  Relapses  of  much  shorter  duration  (Fig.  37) 
may  likewise  exhibit  distinctly  all  the  usual  stages. 

In  addition  to  these  varieties,  relapses  pursuing  a  mild  course,  of 
greater  or  lesser  duration,   often  quite   considerably  protracted,  with 

1  See  Figs.  8,  9,  and  13.  ^  Compare  Fig.  11,  p.  140. 


350  TYPHOID  FEVER. 

irregular,  at  times  outircly  uncharacteristic,  temperature-curves,  are  in 
general  rather  frequent.  The  short  and  the  shortest  relapses  finally 
reproduce,  with  reference  to  character  and  coiu'se,  all  the  features  that 
we  have  become  familiar  with  as  belonging  to  the  symptomatology 
of  mild,  mildest,  and  abortive  cases  of  typhoid  fever.  In  many  the 
fastigium  is  but  of  brief  duration,  and  in  some  cases  it  is  entirely  want- 
ing, in  that  the  temperature  remains  but  temporarily,  often  for  a  few 
hours  only,  at  the  highest  level  reached,  and  then  declines.  Not  less 
varied  is  the  character  of  the  ascent  and  the  decline  of  the  curve  in  the 
mild  and  short  relapses. 

It  is  particularly  interesting  that  the  character  and  the  peculiarities 
of  the  curve  in  the  primary  attack  are  frequently  reproduced  both  in 
the  recrudescence  and  in  the  relapse,  at  times  even  in  a  more  clearly 
defined  manner.  This  applies  especially  to  the  markedly  remittent  or 
intermittent  type  of  curve,  of  which  Fig.  38  constitutes  an  illustration. 

If,  further,  the  character  of  the  individual  parts  of  the  curve  in 
relapses  be  investigated,  a  similarity  will  be  found  to  the  conditions 
usually  present  iu  primary  attacks.  The  form  of  the  ascending  curve  is 
most  frequently  step-like  in  the  customary  manner,  generally  somewhat 
shortened  in  comparison  with  the  same  stage  of  the  primary  attack,  less 
commonly  of  equal  duration. 

In  other  cases  the  temperature  reaches  its  acme  at  a  single  bound  or 
with  but  one  or  two  brief  intermissions  (Figs.  38,  39,  and  46).  Under 
these  circumstances  the  onset  of  the  relapse  with  a  chill,  which  is  other- 
wise very  rare,  is  frequently  observed.  Other  rare  cases  exhibit  the 
peculiar  featm-e  of  one  or  several  marked  fluctuations  in  the  tempera- 
ture, with  considerable  evening  elevation,  before  the  stage  of  definite 
ascent  begins  (Figs.  35  and  40). 

In  addition  to  the  foregoing  varieties  of  curves,  there  occur,  espe- 
cially at  the  beginning  of  relapses  pursuing  an  irregular  course,  a 
number  of  others  which  are  distinctly  related  to  the  like  forms  of  fever- 
ascent  in  the  primary  attack.  It  need  only  be  mentioned  further  in 
this  connection  that  the  onset  may  be  attended  with  abnormally  marked 
remissions  in  the  temperature-curve,  which  may  justify  the  expectation 
of  the  same  or  of  a  wholly  intermittent  character  of  all  the  succeeding 
portions. 

The  course  of  the  temperature  at  the  height  of  the  fever  is  in  relapses, 
as  has  been  emphasized,  in  many  respects  like  that  in  the  primary 
attack.  When  the  fastigium  has  persisted  for  a  considerable  time,  the 
temperature-charts  will  exhibit,  just  as  in  the  primary  attack,  the  char- 
acters of  remittent  continued  fever  or  of  the  more  marked  remittent  or 


RECRUDESCENCES  AND  RELAPSES. 


351 


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terized by  step-like  or  characteristic  steep  curves  (Figs.  36  and  37). 


352 


TYPHOID  FEVER. 


Termination  of  the  relapse  by  critical  decline  is  relatively  rare.  A 
gradual,  entirely  uucbaracteristic  decline,  Avitli  an  irregular,  often  pro- 
tracted course,  or  subsidence  with  marked  intermissions,  is  more  fre- 
quent ;  this  occurs  again  especially  in  cases  in  which  also  the  preceding 
stage  exhibited  a  similar  character  of  curve  (Fig.  39). 

The  pulse  is  generally  more  frequent  in  the  relapse  than  in  the 
primary  attack.  In  women  and  children,  and  in  men  debilitated  by 
the  antecedent  attack,  the  number  of  pulse-beats  is  even  likely  to  be 
unusually  high.  A  pulse  of  120  in  the  evening  is  then  not  a  rare  occur- 
rence, and,  if  the  condition  does  not  persist  for  too  long  a  time,  it  is  not 


Day  of  the  disease. 

24  25  26  27  28  29  30  31  32  33  S^t  35  36  37  38  39  40  h\  42  13  44  'iS  18 

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Fig.  39. 


even  of  especially  serious  import.  In  addition  to  the  increased  frequency, 
the  pulse  during  the  relapse  is  also  characterized  by  great  varial)ility. 
Even  on  slight  physical  or  mental  exertion  it  may  be  beyond  compu- 
tation, and  in  adults  may  reach  130  or  140.  This  instability  of  the 
pulse  makes  itself  appreciable,  as  has  been  seen,  as  early  as  the  period 
of  incubation  of  the  relapse.  An  instructive  illustration  of  the  char- 
acter of  the  pulse  in  this  period  and  during  the  febrile  period  is  afforded 
by  Fig.  35. 

Dicrotism  of  the  pulse  is  definitely  not  so  frequently  observed  during 
the  relapse  as  during  the  primary  attack.  It  quite  generally  fails  to 
appear  even  in  those  cases  in  which  it  was  previously  exceedingly  well 


RECRUDESCENCES  AND  RELAPSES. 


353 


marked.  When  the  manifestation  occurs  at  all,  it  takes  place  in  the 
course  of  the  severe,  protracted  relapse  having  an  csi)ccially  prolonged 
fastigium.  In  such  cases  symptoms  of  cardiac  weakness  also  become 
apparent,  which  otherwise  are  not  common.  Irregularity  of  the  pulse 
also  is  comparatively  rare.  It  likewise  occurs  almost  exclusively  in  the 
most  severe  relapses.  Slowing  of  the  pulse,  which  is  so  cfjmmon  in 
robust  young  men  during  the  primary  attack,  I  have  never  observed  in 
relapses,  even  in  such  individuals. 

The  behavior  of  the  roseolse  in  the  relapse  is  most  important,  espe- 
cially from  a  diagnostic  standpoint.  Their  appearance  may  be  actu- 
ally decisive  in  diagnosis,  especially  when  doubt  exists  whether  the 
reascent  of  the  fever  may  not  be  attributed  to  severe  complications, 

Day  of  the  disease. 


29 


30 


32 


i^JA^^i 


Fig.  40. 

as,  for  instance,  septic  states  or  mihary  tuberculosis.  In  general, 
their  development  during  a  relapse  is  quite  usual — in  my  experience 
scarcely  less  common  than  during  the  primary  attack.  In  290  cases  of 
relapse  examined  with  regard  to  this  point,  I  found  roseolse  doubtful  or 
absent  in  23.7  per  cent.  It  is  true  that,  as  with  regard  to  so  many  condi- 
tions in  cases  of  typhoid  fever,  the  peculiarities  of  individual  epidemics 
must  be  taken  into  consideration  in  this  connection  also.  I  have 
myself  observed  periods  in  which  the  roseolse  were  even  more  frequent 
than  has  just  been  mentioned,  and,  in  addition,  were  also  remarkably 
profuse ;  and  others  in  which  they  were  distinctly  less  conmion  and  less 
abundant.  Their  number  and  extent  in  the  individual  case  are  gener- 
ally somewhat  smaller  than  in  the  primary  attack  ;  but,  on  the  other  hand, 

23 


354  TYPHOID  FEVER. 

the  conditions  observed  duriiii;-  this  jieriod  arc  I'cpoatcd  with  remarkable 
frequency  in  the  relapse.  Only  in  greatly  reduced,  especially  senile  indi- 
viduals, may  the  roseolne  be  remarkably  pale,  small,  and  less  elevated. 
In  such  cases  individual  roseola',  it  is  true,  may  exceptionally  become 
hemorrhagic,  or  actual  petechite  may  appear,  especially  in  tlie  hypogas- 
trium  and  the  adjacent  portions  of  the  thighs.  In  accordance  with  the 
more  rapid  course  of  recrudescences  and  relapses  in  general,  the  roseola? 
also  appear  somewhat  earlier  than  in  the  primary  attack.  Mild  and 
severe  cases  exhibit  little  diiference  in  this  regard.  It  is  possible  that 
in  the  severe  })rotractod  cases  the  eruption  appears  somewhat  later. 
I  have  most  frequently  observed  the  roseolre  to  appear  during  the 
relapse  between  the  third  and  the  fifth  day  ;  somewhat  less  commonly 
on  the  second  or  the  sixth  day  ;  much  less  commonly  at  a  later  period. 
In  only  2  instanced  have  I  observed  roseolte  to  appear  on  the  tenth  and 
the  fourteenth  days  respectively. 

I  have  analyzed  about  300  cases  of  relapses  with  regard  to  this  point. 
The  first  appearance  of  the  roseoliie  from  the  first  to  the  third  day  was  noted 
in  8.7  per  cent.  ;  from  the  fourth  to  the  sixth  day  in  65.5  per  cent.  ;  on 
the  seventh  day  in  14.5  per  cent.  ;  after  the  seventh  day  in  3  per  cent. 

The  duration  of  the  individual  rose-spot  was,  in  general,  not  shorter 
than  in  the  primary  attack.  New  eruptions  and  recrudescences  of  the 
exanthem  also  occurred  in  severe  and  protracted  relapses  just  as  com- 
monly as  in  the  primary  attack. 

Enlargement  of  the  spleen,  as  has  been  mentioned,  often  does  not 
subside  completely  after  the  primary  subsidence  of  the  temperature  in 
cases  in  Avhich  relapses  occur.  It  may  even  remain  palpable  during 
the  entire  interval,  and,  in  connection  with  the  peculiar  character  of  the 
pulse  and  temperature  previously  described,  may  definitely  suggest  the 
impending  relapse.  Before  basing  conclusions  upon  the  state  of  the 
spleen,  however,  one  must  have  assured  himself  that  previous  enlarge- 
ment of  the  organ,  due  to  other  causes,  had  not  existed  prior  to  the 
attack  of  typhoid  fever. 

More  frequent  than  the  persistence  of  splenic  enlargement  is  its  total 
disappearance  in  the  interval  between  the  primary  attack  and  the 
relapse.  The  increase  in  size  then  again  becomes  demonstrable  during 
the  first  days  of  the  relapse,  in  general  somewhat  earlier  than  during  the 
first  attack — in  my  opinion,  between  the  third  and  the  sixth  day.  The 
cases  are  especially  noteworthy,  and  of  importance  from  the  diagnostic 
standpoint,  in  which  enlargement  of  the  spleen  had  been  entirely  wanting 
during  the  primary  febrile  period,  and  became  unequivocally  demon- 
strable during  the  relapse. 


RECRUDESCENCES  AND  RELAPSES.  355 

I  agree  with  Ziemssen/  wlio  j)resents  valual)lc  statistics  in  suppf)rt 
of  liis  statement,  that  the  enlargement  of  the  spleen  during  the  recrudes- 
cence and  the  relapse  is  rarely  greater,  but  generally  is  less,  than  during 
the  primary  attack.  Nevertheless,  1  have  observed  not  a  few  cases 
m  which  enlargement  of  the  spleen,  appreciable  during  the  primary 
attack  only  on  percussion,  became  appreciable  on  palj)ation  during  the 
relapse.  In  this  connection,  it  is  true,  the  great  emaciation  and  the 
relaxation  of  the  abdominal  walls,  probably  also  the  less  marked  meteor- 
ism  during  the  relapse,  may  be  of  some  importance. 

The  symptoms  referable  to  the  intestinal  canal  differ  but  little  from 
those  in  the  primary  attack,  and  at  most  only  in  degree.  Tlie  nieteorism 
rarely  attains  marked  intensity.  The  bowels  are  variable,  as  in  the 
primary  attack.  At  times  there  is  diarrhea,  with  stools  of  characteristic 
color  and  consistence ;  and  at  other  times,  on  the  contrary,  constipation  ; 
or  one  may  alternate  with  the  other.  Anatomic  exainination — this 
statement  is  based  upon  the  conditions  found  in  31  cases  examined 
personally — discloses  without  exception,  in  addition  to  more  or  less 
recent  cicatrices,  or  clean,  almost  healed  ulcers,  resulting  from  the 
primary  attack,  fresh  medullary  swelling  of  l*eyer's  patches  and  the 
solitary  follicles,  in  part  in  process  of  sloughing  or  beginning  ulceration. 
Not  rarely,  under  such  circumstances,  in  addition  to  cicatrized  portions 
of  a  Peyer's  patch,  fresh  infiltration  of  previously  exempt  portions  of 
the  same  patch  may  be  observed.  In  addition,  there  also  occurs  fresh 
swelling  of  the  mesenteric  glands. 

No  definite  relation  exists,  obviously,  between  the  extent  and  the 
intensity  of  the  recent  infiltration  to  those  of  the  previous  one.  I  have 
observed  the  new  infiltration  to  be  quite  extensive  in  the  presence  of 
isolated  cicatrices ;  and,  conversely,  have  observed  only  isolated  fresh 
swollen  patches  or  follicles  after  very  marked  primary  intestinal  lesions. 
On  the  whole,  however,  the  intestinal  lesions  of  the  relapse  are  distinctlv 
less  numerous,  deep,  and  extensive  than  those  of  the  primarv  attack. 
Undoubted  relapses,  associated  with  only  recent  catarrhal  tumefaction  of 
the  mucous  membrane  and  no  alteration  in  the  follicles,  such  as  have  been 
described  especially  by  French  investigators  (Cornil),  have,  as  yet,  not 
occurred  in  my  experience  ;  but  in  the  light  of  current  conceptions  the 
possibility  of  their  occurrence  is  certainly  not  to  be  denied.  In  the 
majority  of  cases  the  fresh  medullary  swelling  also  occurs  in  those  por- 
tions of  the  intestine  preferably  involved  in  the  priman^  attack,  in  the 
midst   of,    or,   more   frequently,   somewhat    remote  from,   the   primarv 

^  Wurzburg.  Jubil.-Gratul.-Schrift,  1882,  and  Deutsch.  Arch.  f.  klin.  Med.,  Bd. 
xxxiv. 


356  TYPHOID  FEVER. 

lesions.  It  does,  however,  occur  not  at  all  rarely  that  portions  of  intes- 
tine aifected  previously  in  slight  degree,  if  at  all,  become  the  seat  of 
marked  alterations  durmg  the  relapse.  Thus,  for  instance,  I  have 
observed  in  a  case  of  "colon-typhoid"  recent  ulcers  and  swelling  in  the 
region  of  the  ileocecal  valve  and  the  adjacent  pw'tions  of  the  ileum, 
which  previously  were  left  almost  intact ;  while  in  other  instances,  con- 
versely, I  have  found  ulceration  of  the  follicles  in  the  large  intestine 
when  the  primary  aflPection  apparently  involved  almost  only  the  lower 
portions  of  the  small  intestine. 

The  slighter  development  of  the  anatomic  alterations  in  general 
explains  also  this  circumstance  that  hemorrhage  and  perforative  perito- 
nitis are  far  less  common  during  relapses  and  recrudescences  than  during 
the  primary  attack.  While,  for  instance,  in  Hamburg  we  obsei^ved 
among  a  total  of  3686  cases  of  typhoid  fever,  153  cases — 4.16  per 
cent. — with  intestinal  hemorrhage,  this  occurred  in  but  4  among  523 
relapses — 0.76   per  cent. 

With  reference  to  the  respiratory  apparatus,  little  i._;  to  be  said.  In 
severe  and  protracted  relapses  bronchitis  generally  again  develops. 
This,  it  is  true,  may  be  of  alarming  severity  and  extent  in  old  and 
debilitated  individuals,  and  may  even  lead  to  hypostatic  congestion. 
The  development  of  pneumonia  and  pleurisy  is  comparatively  rare. 
This  is  applicable  especially  to  true  fibrinous  pneumonia. 

With  regard  to  the  nervous  system  also  there  is  little  of  special 
importance  to  be  mentioned.  In  moderate,  short,  and  mild  relapses 
the  cases  are  in  this  respect  often  remarkably  uncomplicated.  In 
severe  protracted  relapses,  especially  those  that,  as  appears  to  me,  occur 
after  a  mild  primary  attack,  the  patients  at  times  exhibit  violent  delir- 
ium, or  they  may  soon  fall  into  a  state  of  sopor,  and  even  of  alarming 
coma.  Focal  lesions  of  the  central  nervous  system  or  changes  in  the 
peripheral  nerves,  with  corresponding  sequels,  are  distinctly  less  com- 
monly associated  with  relapses. 

Course  and  Terminations  of  the  Relapse. — While  we 
have  as  yet  been  unable  to  distinguish  any  material  difference  between 
a  recrudescence  and  a  relapse  with  regard  to  the  course  of  the  fever  and 
the  changes  in  the  viscera,  such  a  difference  undoubtedly  exists  Avith 
reference  to  the  general  course  and  termination.  The  true  recru- 
descence exhibits  more  frequently  than  the  relapse  a  severe  clinical 
picture,  even  when  the  course  of  the  fever  is  of  the  same  duration  and 
character  in  each.  One  almost  gets  the  impression  that  the  patient  m 
the  relapse,  in  contradistinction  to  the  patient  suffering  from  a  recru- 


RECRUDESCENCES  ANT)  RELAPSES.  357 

descence,  has  already  had  an  opportunity  to  recover  during  the  afebrile 
interval  and  to  fortify  himself  against  the  new  attack. 

Also,  von  Ziemsseu  emphasizes  the  severe  course  of  recrudescences,  lie 
recorded  severe  symptoms  in  50  per  cent,  of  recrudescences,  and  observed 
as  many  as  15  per  cent,  terminate  fatally.  My  own  statistics  are  some- 
what more  favorable.  Of  110  recrudescences,  the  course  was  severe  and 
alarming  in  40,  while  11  per  cent,  terminated  fatally. 

Although  the  actual  relapses  with  a  highly  febrile  and  protracted 
course  may  also  exhibit  a  severe  clinical  picture,  this  is  far  less  com- 
mon, and  the  mortality  is,  on  the  whole,  much  lower,  than  in  the  recru- 
descences. Even  in  the  severest  epidemics  the  mortality  probably 
scarcely  ever  exceeds  5  per  cent. ;  2.5  per  cent.,  or  at  most  4  per  cent., 
is  probably  the  usual  mortality. 

In  the  epidemic  at  Hamburg  the  mortality  during  relapses  was  relatively 
high,  namely,  4.9  per  cent.  (Among  all  fatal  cases  of  typhoid  fever,  the 
proportion  of  those  occurring  during  relapses  was  0.7  per  cent.j  Our 
statistics  at  Leipsic  exhibit  a  mortality  of  not  quite  2  per  cent.  ;  those  of 
Ziemssen,  2.8  per  cent.  Steinthal,'  it  is  true,  records  8.8  per  cent.  As  this 
estimate,  however,  is  based  upon  only  45  relapses,  accidental  influences  are 
not  excluded.  The  same  is  true  of  the  unfavorable  experiences  of  Murchi- 
son,^  whose  statements  were  based  upon  only  10  cases,  and  who,  certainly 
without  reason,  considers  that  relapses,  as  a  rule,  are  more  severe  than  the 
primary  attacks.  Further,  the  severity  of  the  relapse,  and  therefore  also 
its  mortality,  vary,  like  so  many  other  features  of  typhoid  fever,  undoubt- 
edly not  inconsiderably  in  accordance  with  temporal  and  local  influences. 
Under  all  conditions,  however,  the  mild  cases  are  far  more  frequent  than 
the  severe,  which,  in  general,  may  be  estimated  at  from  10  to  15  per  cent. 
We  observed  at  Hamburg,  among  496  relapses :  Mild,  365 — 73.8  per  cent.  ; 
moderately  severe,  78 — 15.6  per  cent. ;  severe,  53 — 10.6  per  cent. 

The  duration,  the  height,  and  the  character  of  the  fever,  as  well  as 
intercurrent  local  disorders,  are  especially  of  determining  influence  with 
regard  to  the  character  of  the  course  and  the  termination.  A  special 
position  with  regard  to  prognosis  is  occupied  by  the  protracted  relapses 
attended  with  irregular,  markedly  remittent  fever,  as,  both  m  adults  and 
in  children,  they  are  at  no  time  likely  to  give  rise  to  serious  concern. 

It  is  an  important  question  whether  the  character  and  the  severity 
of  the  relapse  depend  upon  those  of  the  primary  attack.  Undoubtedly, 
as  has  been  pointed  out,  it  may  be  observed  in  many  cases  that  the 
original  character  of  the  temperature-curve  is  reproduced  in  recrudes- 
cences and  relapses ;  while  this  feature  is  less  marked  with  regard  to 
the  remaining  typhoid  symptoms — the  roseolae,  the  enlargement  of  the 
spleen,  and  the  diarrhea.  With  regard  to  the  temperature-curs^e,  it  has 
been  mentioned  that  it  frequently  happens  that  if  the  curve  exhibits  an 
intermittent  or  remittent  character  during  the  primary  attack  this  is 

'  Deuisch.  Arch.  f.  klin.  Med.,  1884,  Bd.  xxxiv.  ^  Loc.  cit. 


358  TYPHOID  FEVER. 

likely  to  be  repeated  in  the  relapse  or  to  become  even  more  clearly 
marked  (see  Fig.  38).  The  character  of  the  rise  and  of  the  decline  of 
the  temperature  also  frequently  resembles  that  observed  in  the  jirimary 
attack.  This  becomes  especially  conspicuous  in  the  less  frequent 
varieties ;  for  instance,  the  ascent  at  a  single  stroke,  or  the  critical 
decline.  Only  recently  I  observed  a  remarkable  coincidence  likewise 
Avith  regard  to  the  character  of  the  curve  at  the  height  of  the  fever,  in 
that  a  convalescent  from  a  hyperpyretic  attack  of  ty])hoid  fever  exhibited 
also  during  the  relapse,  lasting  but  a  few  days,  cNcuing  temperatures  of 
more  than  41°  C. 

With  regard,  however,  to  the  severity  or  the  mildness  of  the  course 
of  the  relapse,  as  compared  with  that  of  the  primary  attack,  it  must  be 
considered  as  established  that  there  is  no  rule.  Thus,  in  the  sequence 
of  mild  attacks — abortive,  ambulatory,  or  afebrile  typhoid  fever — the 
most  severe  protracted  relapses  may  occur.  I  believe,  in  agreement 
"with  a  large  number  of  writers  (Ziemssen,  Liebermeister,  Jaccoud, 
Steinthal,  Goth,  and  others),  I  may  state  that  this  is  quite  frequent. 

The  duration  of  the  afebrile  interval  between  the  primary  attack  and 
the  relapse  appears  to  be  without  material  influence  upon  the  course  of 
the  latter.  It  is  my  impression,  however,  that  relapses  occurring  espe- 
cially late  more  frequently  pursue  a  mild  course.  The  duration  of  the 
relapse  is,  in  the  large  majority  of  cases,  from  six  to  fifteen  or  twenty- 
one  days.  Periods  of  from  twenty -two  to  tw^enty-five  days  are  some- 
Avhat  less  common,  and  those  of  from  twenty-six  to  forty  days  are 
observed  only  exceptionally.  Relapses  of  more  than  forty  days'  dura- 
tion I  have  observed  in  but  2  mstances,  one  of  forty -three  and  another 
of  forty -five  days. 

Von  Ziemssen  noted  that  the  duration  in  101  relapses  which  he  collected 
varied  between  four  and  thirty-five  days.  In  the  overwhelming  majority  (96) 
it  varied  between  five  and  twenty-one  days.  The  findings  of  Jaccoud,  who 
noted  the  most  frequent  duration  as  from  eight  to  twenty-one  days,  and  our 
own  statistics  at  Leipsic  (Berg),  where  of  210  relapses,  182 — 86.6  per  cent 
■ — lasted  from  ten  to  twenty  days,  are  quite  similar.  An  analysis  of  the  523 
cases  of  relapse  observed  in  Hamburg  in  1886-1887  discloses  that  likewise  the 
great  majority  of  cases,  namely,  402 — 76.9  per  cent. — lasted  between  five 
and  twenty  days. 

Relapses  of  shorter  duration,  as,  for  instance,  less  than  six  days, 
are,  however,  by  no  means  rare.  If  it  be  correctly  assumed  that  recru- 
descences and  relapses  are  really  only  repetitions  of  the  primary  attack, 
it  is  justifiable  to  conclude  that  inasmuch  as  mild  and  incomplete  pri- 
mary attacks  may  be  observed,  abortive  and  incomplete  relapses  also 
occur.     The  true  nature  of  a  portion  of  these  is  further  disclosed  by 


RECRUDESCENCES  AND  RELAPSES.  359 

renewed  enlargement  (^f  the  spleen  and  reappeurance  of  roseola),  in  asso- 
ciation with  persistent  elevation  of  temperature  for  only  a  few  days.  In 
other  cases,  with  a  reappearance  of  the  fever  for  a  short  time  after  an 
afebrile  interval  of  greater  or  less  duration,  the  interpretation  of  a 
relapse,  if  roseolse  and  splonie  eidargement  are  wanting,  is  to  Ix;  based 
only  upon  the  possibility  of  excluding  otlier  febrile  ])rocesses.  That,  on 
account  of  the  inadequacy  of  our  diagnostic  means,  great  caution  should 
be  observed  in  this  connection,  and  that  in  the  individual  case  the 
diagnosis  had  better  be  left  in  doubt,  need  scarcely  be  emphasized. 
Transitory  elevation  of  temperature,  not  dependent  upon  local  discuisc, 
has,  upon  the  suggestion  of  Biermer,  been  designated  "  after-fever." 
Some  of  the  cases  in  which  this  occurs  are  certainly,  by  reason  of 
their  nature  and  development,  to  be  included  among  relapses,  so  that  it 
appears  more  appropriate  for  these,  instead  of  employing  the  undistine- 
tive  expression  of  Biermer^,  to  employ  the  designation  shortest  relapses 
or  "abortive  relapses." 

In  quite  rare  cases,  after  the  fever  had  subsided  and  the  patient  had 
for  days  exhibited  subnormal  temperature,  I  have  observed  marked 
fluctuations  in  the  temperature-curve  with  evening  elevations,  not,  how- 
ever, exceeding  37.5°  C,  associated  with  headache,  malaise,  restlessness, 
and  even  slight  stupor,  this  condition  lasting  for  from  several  days  to  a 
week.  The  simultaneous  appearance  of  roseolse,  as  well  as  the  further 
circumstance  that  the  enlargement  of  the  spleen  had  not  wholly  dis- 
appeared after  defervescence,  but  had  rather  increased  somewhat  during 
the  period  of  relative  temperature-elevation,  justified  me  in  considering 
these  conditions  also  as  relapses.  It  will  be  seen  that  the  agreement 
between  the  various  varieties  of  course  of  the  primary  attack  and  thOse 
of  the  relapse  is  so  complete  that  one  may  even  speak  of  "  afebrile 
relapses." 

The  frequency  of  the  occurrence  of  relapses  appears,  as  has  been 
mentioned,  to  vary  considerably  in  accordance  with  temporal  and  local 
influences  and  in  different  epidemics.  Probably  the  great  diversity  of 
statement  among  writers  in  this  connection  is  dependent  also  upon 
differences  in  conception.  If,  as  is  not  done  in  all  statistics,  the 
recrudescences  are  separated  from  the  relapses,  it  will  be  found  that 
the  frequency  of  occurrence  of  the  latter  is,  on  the  whole,  in  from  6 
to  12  per  cent,  of  all  cases. 

In  Leipsic,  we  estimated  the  average  of  fourteen  years,  which,  it  is  true, 
varied  considerably  among  themselves,  at  12  per  cent.  ;  while  in  Hamburg, 
in  the  year  1886-1887,  14.2  per  cent,  of  relapses  were  observed — undoubtedly 
a  high  figure,  in  comparison  with  which  the  recrudescences  in  the  strict 


360  TYPHOID  ;FEVER. 

seuse — 1.8  per  ceut. — exhibited  a  great  disproportion.  The  extremes  that 
may  be  reached  l)v  various  writers  in  accordauce  with  the  interpretation  of 
the  term  relapse  and  with  temporal  and  local  diHerences  will  be  shown  by 
the  following  statement,  which  I  have  already  had  prepared  in  part  in  the 
dissertation  of  Schulz.  Of  relapses,  there  occurred,  according  to  Lind- 
wurm,*  in  Munich,  1.4  per  cent.  ;  Murchison,''  in  London,  8.0  per  cent.  ; 
Biermer  (Fleischel),^  3.3  per  cent.  ;  Beetz,  Heiuier  (1874-1877),^  4.0  per 
cent.  ;  Ebstein,'  in  Breslau,  4.3  per  cent.;  Eichhorst,''  in  Zurich  (summer  of 
1884),  5.6  per  cent.  ;  Griessinger,"  in  Zurich,  G.O  per  cent. ;  CJerhardt*'  (col- 
lection from  reports  of  epidemics),  6.3  per  cent.  ;  Bteintlud,''  in  Leipsic 
(1877-1881),  7.5  per  ceut.  ;  Liebermeister,'"  in  Basle  (1867-1874),  8.6  per 
cent.;  Goth,"  in  Kiel  (1871-1885),  8.7  per  cent.;  Biiumler^-  (German 
Hospital  of  London),  10.9  per  cent;  Biilau,"  in  Hamburg  (1875),  11.4 
per  ceut.  ;  Butz,''  in  ^lunich  (1878-1883),  12.5  per  cent.  ;  von  Ziemssen,'^  in 
Munich  (1878-1881),  13.0  per  cent.;  Freundlich,'"  in  Freiburg,  14.0  per 
cent. ;  Weil,'"  in  Heidelburg,  17.0  per  cent. 

Age  and  sex  are  not  witliout  influence  upon  the  occurrence  of 
relapses.  With  reference  to  age,  it  may  be  said  that  relapses  undoubt- 
edly occiu'  more  frequently  in  young  persons  than  in  the  later  years  of 
life.  This  is  exhibited  with  especial  distinctness  in  the  typhoid  fever 
of  childhood,  and  here,  as  we  shall  subsequently  see,  even  extends  to 
repeated  relapses. 

Analysis  of  5302  cases  at  Hamburg  and  Leipsic  disclosed  733  relapses — 
13.8  per  ceut.  Among  these,  there  occurred  in  adults  4687  cases,  with  630 
relapses — 13.4  per  cent.  ;  in  children,  615  cases,. with  103  relapses — 16.8  per 
cent. 

The  differences  with  regard  to  age  appear  more  striking  in  a  study  of 
the  statistics  of  Leipsic  alone,  which  show  12.5  per  ceut.  of  relapses  in  adults 
and  19.1  per  ceut.  in  children. 

The  differences  are  less  marked  with  regard  to  the  influence  of  sex 
upon  the  frequency  of  relapses.     AVith  Griessinger  and  others,  I  am 

'  Aerztl.  Intelligenzbl.,  1873,  and  Korber,  Inaug.  Diss.,  Munich,  1874. 

^  Loc.  cit.  ^  Inaug.  Diss.,  Zurich,  1873. 

*  "Statistik  der  Typhusbewegung  auf  der  med.  Klinik  des  Herrn  Prof.  Zienis- 
sen,"  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  xvi.,  xvii.,  u.  xxiii. 

*  Die  Recidive  des  Typhus,  Breslau,  1869. 

^  Deutsch.  Arch.f.  kiln.  Med.^  Bd.  xxxix.,  S.  297. 
'  Loc.  cit.,  S.  240. 

8  Deutsch.  Arch.f.  klin.  Med.,  1873,  Bd.  xii.,  S.  8. 

9  Ibid.,  1884,  Bd.  xxxiv.,  S.  358,  Inaug.  Diss. 

^^  Loc.  dt,  p.  198.  "  Loc.  cit.,  p.  146. 

I''  Loc.  cit.,  p.  397. 

'='  Deutsch.  Arch.f.  klin.  Med.,  Bd.  xviii.,  S.  107. 

"  "Statistik  der  Typhusbewegung  auf  der  med.  Klinik  des  Herrn  Prof.  Ziemssen 
von  1878-1883,"  Ibid.,  Bd.  xxxviii.,  S.  320. 

15  "Ueber  deTyphusrecidive,"  Ibid.,  Bd.  xxxiv.,  S.  376. 

^^  Loc.  cit.,  p.  324. 

*^  Zur  Pathologic  ^ind  Thernpie  des  Abdojninaltyphus,  1885. 


BECBUDESCENCES  AND  RELAPSE!^. 


361 


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in  the  latter. 


362 


TYPHOID  FEVER. 


In  Hamburg,'  the  following  fi<rurt'S  were  ol)serYecl 


1886 
1887 


Males. 
11.9 
13.3 


Females. 
10.3 
15.U 


Analysis  of  the  I^eipsic  ptatistic.<  exhil)it.><  simihir  results  for  a  number  of 
the  years,  but,  on  the  whole,  discloses  no  noteworthy  difi'ereiices. 


In  most  cases  the  disease  terminates  with  a  single  recrudescence  or  a 
single  relapse.     Both   may,   however,  be  variously  repeated.      It  may 


RECRUDESCENCES  AND  RELAPSES.  363 

happen  that  in  one  patient  only  recrudescences  up  to  three  occur,  while 
another  is  attaclvcd  only  by  relapses.  The  occurrence  of  recrudescence 
and  relapse  in  the  same  patient  is  not  uncommon.  Under  such  circum- 
stances the  recrudescence  almost  always  occurs  in  the  course  of  the 
primary  period  of  defervescence ;  and  then,  after  an  afebrile  period  of 
varying  length,  one  or  several  relapses  occur  (Fig.  42). 

It  is  quite  rare,  and  to  my  knowledge  nowhere  mentioned,  that  a 
recrudescence  follows  a  protracted  relapse — then  generally  moderately 
severe  or  severe — before  the  temperature  has  returned  to  the  normal 
(Fig.  43).  I  lost  such  a  patient  at  the  height  of  such  a  recrudescence 
complicating  a  relapse,  with  symptoms  of  the  most  profound  intoxi- 
cation. Among  the  most  frequent  of  the  possibilities  mentioned  is  the 
repeated  relapse,  there  being  generally  but  two,  and  rarely  three.  Four 
and  five  relapses  are  among  the  greatest  exceptions.  Under  such 
circumstances  every  individual  relapse  should  be  most  critically 
scrutinized. 

Ziemssen  found,  among  108  cases  of  typhoid  fever  with  relapse,  only -6  in 
which  this  was  repeated.  In  but  1  of  these  he  believed  himself  justified, 
although  not  absolutely  certain,  in  assuming  the  occurrence  of  three  relapses. 
Among  the  523  cases  with  relapse  that  we  observed  in  the  epidemic  at  Ham- 
burg from  1886  to  1887,  in  474 — 90.6  per  cent. — there  occurred  but  one 
relapse  ;  two  relapses  in  44 — 8.4  per  cent.  ;  and  in  only  5  cases — 0.9  per  cent. 
— among  this  large  number  were  three  relapses  observed.  I  have  personally 
observed  four  relapses  in  each  of  2  cases ;  and  only  recently  I  have  seen  a 
case  in  which,  following  upon  a  severe  recrudescence,  three  relapses  occurred, 
the  shortest  of  which  was  three  weeks  in  duration.  I  would  further  empha- 
size the  fact  that  the  proportion  of  8.4  per  cent,  of  cases  in  which  two 
relapses  occurred,  as  disclosed  by  the  Hamburg  statistics,  exceeds  that 
yielded  by  my  previous  and  subsequent  experience.  I  believe  the  occur- 
rence of  such  cases  to  be,  on  the  average,  much  less  frequent — 4  per  cent, 
would  probably  represent  the  usual  conditions. 

With  reference  to  the  severity  of  repeated  relapses,  this  appears  to 
me  to  be  generally  slighter  than  that  of  the  first  relapse  or  of  the  recru- 
descence. The  contrary,  however,  is  not  altogether  rare.  Thus,  last 
year  I  saw  in  consultation  a  second  extremely  severe  relapse  of  twenty- 
six  days'  duration  occur  nine  days  after  the  termination  of  the  first 
mild  relapse  of  only  eleven  days'  duration ;  and  also  previously  I 
had  repeatedly  encountered  cases  in  which  the  second  relapse  exceeded 
the  first  in  duration  by  a  third  and  even  by  half.  I  have  observed 
even  the  third  relapse  to  be  considerably  more  severe  and  more  pro- 
tracted than  the  two  preceding  ones. 


364 


TYPHOID  FEVER. 


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RECRUDESCENCES  AND  RELAPSES.  365 

Von  Ziemsseu  has  made  the  followiug  iiiHtructive  tabulation  of  4  cases 
of  double  relapse : 

Duration  of  the  first  relapse.  iJuratiou  of  the  seeond  relapse. 

First  case Three  weeks.  Fourteen  days. 

Second  case Three  weeks.  Fifteen  days. 

Third  case Eleven  days.  Seventeen  days. 

Fourth  case Fourteen  days.  Twenty-three  days. 

Just  as  the  occurrence  of  the  single  relapse  bears  some  relation  to 
the  age  of  the  patient,  so  age  also  appears  to  play  a  rote  in  repetitions 
of  relapses  and  recrudescences.  Here  also  young  persons  are  distinctly 
more  frequently  attacked.  Thus,  at  Hamburg,  among  44  cases  of 
double  relapse,   12  occurred  in  children. 

If,  in  conclusion,  a  few  remarks  be  made  concerning  the  mode  of 
development  of  relapses  and  recrudescences,  it  should  first  be  again 
rnentioned  that  at  the  present  day  these  are  generally  considered  to  be 
repetitions  of  the  primary  morbid  process,  dejjendent  upon  the  infection 
responsible  for  this,  and  not  the  result  of  a  new  invasion  by  typhoid- 
bacilli.  Also,  no  one  doubts  any  longer  that  certain  influences  whicli 
were  formerly  considered  as  the  cause  of  relapses  play  only  the  part  of 
factors  contributory  to  their  development.  This  view  must  be  adhered 
to  in  spite  of  certain  hyj^ercritical  objections.  Emotional  disturbances, 
premature  mental  activity,  and,  among  injurious  physical  influences, 
premature  getting  out  of  bed,  and,  above  all,  dietetic  errors,  must  all  be 
regarded  in  this  light.  That  these  are  contributory  factors,  however, 
must  be  expressly  emphasized,  notwithstanding  Murchison's  views — to 
which  Uhle  and  others  agree — to  the  contrary,  and  even  though  we 
have  as  yet  no  knowledge  concerning  the  mechanism  of  their  unfavor- 
able influence.  It  would  be  a  source  of  great  danger  to  the  typhoid 
patient  if  this  fundamental  principle  were  neglected.  I  have  also  noticed 
relapses  follow  upon  a  number  of  other  influences  comparable  to  dietetic 
error.  Thus,  but  a  year  ago,  I  observed  such  an  occurrence  after  the 
institution  of  treatment  for  tapeworm. 

The  patient  in  question,  a  previously  healthy  house-servant  forty-three 
years  old,  was  brought  to  the  clinic  complaining  of  general  malaise  and 
anemia,  the  diagnosis  of  the  fundamental  trouble  being  indefinite.  He 
appeared  to  be  entirely  free  from  fever,  and  exhibited  for  a  time,  not- 
withstanding increased  pulse-frequency,  persistent  subnormal  temperature 
(morning,  36°  C.  ;  evening,  scarcely  36.5°  C).  It  could  not  be  determined 
from  the  history  whether  fever  had  existed  during  the  period  prior  to  admis- 
sion. As  the  pallid,  considerably  emaciated  man  lost  over  two  pounds 
during  eighteen  days'  residence  in  the  hospital,  in  spite  of  careful  nursing, 
the  discovery  of  a  Tsenia  mediocanellata  was  received  as  a  welcome  thera- 
peutic indication.  On  the  third  day,  after  successful  treatment  for  the' 
tapeworm,  the  temperature  began  to  rise,  and  there  followed  a  febrile  state 
of  seventeen  days'  duration,  which,  from  the  character  of  the  curve,  enlarge- 


366  TYPHOID  FEVER. 

ment  of  the  spleen,  roseolse,  thin  stools,  and  diazo-reaction,  proved  to  be 
typhoid.  Undoubtedly,  the  patient  came  under  observation  during  conva- 
It'ticence  from  an  attack  of  ambulatory  typhoid  fever,  and  he  suH'ered  a 
relapse  of  the  primary  condition  in  consequence  of  the  treatment  instituted. 

A  question  formerly  earnestly  and  frequently  discussed  was  whether 
antipyretic  treatment  of  typhoid  fever,  especially  that  with  cold  baths, 
caused  an  increase  in  ihc  frequency  of  relapses.  Many  physicians,  even 
the  most  enthusiastic  advociites  of  those  methods,  were  unwilling  to  dis- 
regard the  possibility  of  an  unfavorable  eifect  in  this  regard  (Liebcr- 
meister,  Biermer,  Ley  den,  Goltdammer),  while  others  (Leich  ten  stern, 
Yogi)  expressed  a  contrary  opinion.  If  the  abundant  literature  upon  the 
antipyretic  method  of  treatment  be  studied  with  regard  to  this  question, 
it  will  be  found  that  in  certain  places  and  at  certain  times,  under  iden- 
tically the  same  application  of  bath-treatment,  the  number  of  relapses 
exhibits  the  greatest  variation.  I  have  personally  likewise  observed 
such  \-ariable  results  at  different  times,  when  I  employed  antipyretics 
and  baths  more  systematically  than  at  present,  that  I  am  unable  to  con- 
vince myself  that  the  methods  in  question  exert  any  eifect  in  causing 
rela]>ses.  The  question,  besides,  no  longer  occupies  the  prominent  posi- 
tion it  formerly  did,  inasmuch  as  we  have  gained  other  therapeutic 
points  of  view. 

CONVALESCENCE. 

Accurate  knowledge  of  the  peculiarities  of  the  period  of  convales- 
cence, and  accordingly  of  its  careful  supervision,  is  not  less  important 
than  that  of  the  earlier  stages  of  the  disease.  In  accordance  with  the 
extraordinary  variability  in  the  severity,  the  duration,  and  the  symp- 
tomatology of  tho  disease,  the  clinical  picture  of  convalescence  is  also 
extremely  variable.  It  is,  besides,  especially  influenced  by  age,  sex, 
constitution,  complications,  and  relapses.  In  general,  it  may  be  stated 
that  typhoid  fever  is  one  of  those  acute  infectious  diseases  that  most 
frequentlv  either  terminates  fatally  or,  at  the  conclusion  of  convalescence, 
in  complete  restoration  to  health.  Invalidism,  sequels,  and  permanent 
defects  are  comparatively  less  common  after  it  than  after  many  other 
infectious  diseases.  Indeed,  it  cannot  be  denied  that  the  statement 
often  made  by  the  laity  that  the  general  condition  after  recovery  often 
becomes  better  and  more  flourishing  than  prior  to  the  disease,  particu- 
larly in   young   persons,  is  not  without  foundation. 

GENERAL  COURSE. 
With   the  advent  of  convalescence,  the  beginning  of  which  can  be 
dated  from  the  first  day  of  persistent  defervescence,  the  condition  of  the 


CONVALESCENCE.  367 

patient  is  extremely  varial)le,  in  accordance  with  the  course  of  the  ante- 
cedent attack  and  individual  circumstances.  In  children  and  in  pre- 
viously healthy  young  adults  the  disease  naturally  is  in  general  foUfjwcd 
by  slighter  disturbances  that  are  more  rapidly  recovered  from  than  in 
older  individuals  or  in  those  already  debilitated  in  advance  of  tlie  attacJc. 

Under  all  circumstances,  however,  with  the  onset  of  convalescence 
from  severe  attacks  of  typhoid  fever,  the  patients,  of  whatever  age  and 
constitution,  exhibit  considerable  impairment  of  the  general  condition. 
Emaciation  and  anemia  are  most  conspicuous.  The  symptoms  of 
the  anemia  of  convalescence,  which  often  are  most  profound,  are  found 
on  careful  examination  to  be  dependent  especially  upon  alterations  in 
the  number  and  character  of  the  red  blood-corpuscles  and 
upon  variations  in  the  percentage  of  hemoglobin.  The  red  blood- 
corpuscles  and  hemoglobin,  as  in  the  earlier  stages,  usually  pursue 
a  parallel  course  also  during  convalescence,  but  not  rarely  their  curves 
diverge.  The  reduction  in  hemoglobin  and  red  blood-corpuscles,  which 
is  likely  to  be  less  in  men  and  otherwise  robust  persons  m  general  than 
in  women  and  debilitated  individuals,  will  have  reached  its  maximum  in 
the  majority  of  cases,  according  to  observations  made  at  my  clinic,^ 
before  the  termination  of  the  fever,  subsequently  to  rise  slowl}'  again. 
Less  commonly,  the  minimum  percentage  of  hemoglobin  remains 
unchanged  for  a  certain  time,  during  the  first  part  of  the  afebrile  stage, 
or  the  hemoglobin  may  undergo  still  further  reduction.  It  is  interesting 
that  patients  who  have  become  markedly  anemic,  on  the  contrary, 
frequently  exhibit  immediately  a  steady  and  comparatively  rapid 
increase  in  the  percentage  of  hemoglobin.  Thus,  Kolner 
observed  in  a  patient  who  had  become  particularly  anemic  an  increase 
of  31  per  cent,  in  the  hemoglobin  witliin  six  weeks,  and  in  other 
patients,  not  at  all  rarely,  an  increase  of  from  10  to  15  per  cent,  in 
the  course  of  a  week.  Especially  in  such  cases  of  remarkably  rapid 
reproduction,  however,  have  we  occasionally  observed  the  occurrence  of 
a  stationary  period  or  even  a  transitory  diminution. 

The  not  uncommon  divergence  m  the  relation  of  the  red  blood-cor- 
puscles to  the  hemoglobin  that  has  been  mentioned  is  referable  especially 
to  the  time  and  the  circumstances  of  the  greatest  reduction  in  number. 
While  in  the  majority  of  cases  the  number  of  red  cells  pursues  a  parallel 
course  with  the  reduction  in  hemoglobin,  it  occasionally  exhibits  a  still 
further  progressive  diminution  extending  into  the  afebrile  period,  when 
the  hemoglobin  has  already  begun  to  rise  again.     Even  at  a  later  stage, 

1  Kolner,  Inaug.  Diss.,  loc.  cit.,  and  Arch.  f.  klin.  Med.,  Bd.  1.  See  also  the 
•extensive  bibliographic  references  in  this  article. 


368  TYPHOID  FEVER. 

a  considerable  diminution  in  number,  Mhich  y\e  have  observed  to  reach 
half  a  milHon,  and  even  more,  sometimes  occurs. 

In  all  cases,  even  the  moderately  severe  and  mild  cases,  the  restom  • 
tion  of  the  condition  of  the  blood  to  that  present  before  the  attack  takes 
place  but  slowly.  Even  after  the  lapse  of  seven  weeks  we  have  found 
that  the  normal  number  of  red  blood-cells  and  the  corresponding  per- 
centage of  hemuglobiu  have  not  been  entirely  regained.  More  or  less 
marked  deficiency  in  the  regeneration  of  the  blood  was  observed  in 
almost  all  cases  examined  with  reference  to  this  point  at  a  time  at  which 
they  could  be  safely  dismissed  and  considered  able  to  return  to  work. 

The  emaciation  of  typhoid  patients,  which  has  been  studied  by  Schar- 
lau,  Leyden,  Botkin,  and  others,  and  subsequently  with  especial  care  by 
Kohlschiitter  "^  and  Cohiu,^  is,  in  comparison  with  the  duration  of  the 
disease  and  with  the  amount  of  weight  lost  in  other  acute  infectious  dis- 
eases, not  so  great  as  would  be  anticipated.  It  is  naturally  most  marked 
in  the  cases  of  long  duration  and  with  high  fever,  but  also  after  moder- 
ate and  mild  cases  the  loss  of  weight  indicates  the  serious  character  of 
the  recent  infection  and  its  deleterious  influence  upon  the  tissues. 

All  parts  of  the  body  apparently  share  in  the  emaciation — in  what 
relation  to  one  anotlier  has  as  yet  not  been  sufficiently  determined.  The 
loss  in  weight  is  most  manifest  during  the  febrile  period.  The  rapidity 
of  this  loss  attains  its  maximum,  in  cases  of  normal  or  more  protracted 
duration,  at  the  end  of  the  second,  more  frequently  still  in  the  course  of 
the  thii'd,  week ;  from  that  time  on  until  complete  defervescence  it  con- 
tinues more  slowly,  not  rarely  in  progressively  lessening  degree.  After 
defervescence  the  bodily  weight  again  increases,  in  general  far  more 
slowly  than  it  declined ;  naturally,  more  rapidly,  at  times  even  with 
remarkable  rapidity  after  mild  attacks,  and  especially  in  children  and 
in  young,  previously  healthy  individuals. 

It  is  a  most  remarkable  fact  that  has  not  been  sufficiently  dwelt  upon, 
if  at  all,  by  even  careful  writers,  that  in  a  considerable  number  of  cases, 
after  complete  defervescence,  during  the  first,  even  during  the  second, 
with  exceeding  rarity  during  the  third,  week  of  convalescence,  the  loss 
of  weight  still  progresses.  This  can  be  observed  most  frequently 
after  severe,  long-continued  attacks  ;  occasionally,  however,  also  after 
short  attacks  of  mild  course.  I  have,  under  such  circumstances,  noted 
a  loss  of  weight  of  as  much  as  from   1.5  to  2  kilograms  during  the  first 

*  Volkmann's  Sammlung  inn.  Med.,  No.  103. 

'  Bull.  gen.  de  iherap..  May  15,  1887.  My  own  observations  are  based  upon 
the  weekly  weights  of  all  my  typhoid  patients,  the  details  upon  the  analysis  of  92  cases 
at  the  Leipsic  clinic,  undertaken  by  my  assistant,  Dr.  Hirsch. 


CONVALESCENCE.  369 

week  of  convalescence.  I  am  unable  to  give  a  satisfactory  explanation 
for  this  phenomenon.  Some  of  the  evidence  indicates  that  increased  loss 
of  water  from  the  tissues  plays  some  role  in  this  connection.  I  liave  in 
a  number  of  instances  observed  polyuria,  increase  in  the  specific  gravity 
of  the  blood,  and  a  relative  increase  in  the  number  of  red  blood-coq)us- 
cles,  in  association  therewith. 

The  loss  in  body-weight  in  the  course  of  the  fever  appears  to  take 
place  not  abruptly,  but  uniformly,  as  Cohin,  by  tlie  use  of  suitable 
apparatus,  weighing  the  typhoid  patient  repeatedly  for  twelve  days,  has 
demonstrated.  The  average  loss  of  weight  a  day  in  a  mild,  uncom- 
plicated case  was  estimated  by  the  same  observer  at  260  grams.  Other 
writers,  as,  for  instance,  Botkin,  observed  it  to  reach  800  grams  and 
above  in  severe  cases. 

The  total  weight  which  patients  have  lost  at  the  beginning  of  con- 
valescence is  at  times  quite  alarming.  I  have  noted  in  an  adult,  after 
a  severe,  long-protracted  attack,  with  various  complications,  a  reduction 
of  41  per  cent,  in  the  original  weight,  and  in  mild  and  moderately  severe 
cases  I  have  seen  even  as  great  a  loss  as  10  and  19  per  cent,  respectively. 
It  is  worthy  of  note  that  in  children  I  found  the  maximum  loss  of  weight 
to  be  9  per  cent.  These  high  figures  may  be  contrasted  with  some 
extremely  low  figures  collected  from  a  large  number  of  observations. 
Thus,  in  mild  cases  I  have  observed  only  from  1  to  1.1  per  cent,  loss 
of  body-weight,  and  I  have  even  seen  severe  cases  in  which  the  total 
loss  was  not  more  than  from  1.5  to  3  per  cent. 

The  conditions  during  convalescence  in  detail  have  been  considered 
in  various  parts  of  this  work.  Thus,  the  behavior  of  the  temperature 
during  this  period  was  fully  considered  on  pages  140  and  141.  It  was 
shown  that  m  almost  all  well-marked  cases — and  generally  the  more  dis- 
tinctly and  the  more  protractedly,  the  severer  the  course — the  body-tem- 
perature declined  below  the  normal  soon  after  defervescence,  and  grad- 
ually rose  again,  reaching  the  previous  individual  level  only  after  days 
or  weeks.  It  was  seen,  further,  that  during  this  period  of  subnormal 
temperature,  assuming  a  condition  of  perfect  quiet  on  the  part  of  the 
patient,  the  daily  fluctuations  are  slight,  often  less  marked  than  in  per- 
fectly healthy  individuals ;  but  that  they  become  extremely  marked, 
however,  in  consequence  of  even  slight  physical  or  mental  exertion. 
These  peculiarities  of  the  curve  are  generally  so  constant,  and  appear  in 
so  typical  a  manner  after  an  attack  of  ordinary  course,  that  they  consti- 
tute important  criteria  in  the  recognition  of  convalescence.  I  have  long 
been  in  the  habit  of  considering  convalescence  after  moderately  severe 
and  severe  attacks  not  completely  estabhshed  until  they  appeared.    Daily 

24 


370  TYPHOID  FEVER. 

experience  teaches  that  when  they  are  wanting  relapses  and  complications 

are  likely  to  occur. 

The  pulse,  us  has  like\vi.-<e  been  pointed  out,  is,  in  contrast  to  the 
temperature,  rarely  slowed  at  the  beginning  of  the  period  of  convales- 
cence, and  then  probably  only  in  special  cases — most  frequently  is  rela- 
tively slowed  in  elderly  individuals,  or,  conversely,  in  especially  vigorous 
men.  Generally,  it  is  slightly  or  moderately  full  and  tense  ;  after  mild 
cases  it  is  of  normal  frequency,  and  after  severe  attacks  and  in  irritable 
individuals  is  of  greater  frequericy — reaching  in  the  neighborliood  of  100 
in  the  evening.  A\"onien  and  children  frequently  show  a  still  higher  rate. 
In  addition,  the  pulse-frequency  is  extremely  unstable,  not  only  in  the 
stage  of  subnonnal  temperature,  but  also  often  long  after  this.  Up  to 
the  time  of  getting  up,  slight  mental  exertions  or  physical  disturbances 
cause  marked  increase  in  the  number  of  pulse-beats,  this  increase  often 
rajndly  disappearing  again.  This  phenomenon  may  become  especially 
striking  and  even  actually  alarming  to  the  inexperienced  physic^ian  and 
the  friends,  when  the  patient,  by  reason  of  his  otherwise  favorable  con- 
dition, has  been  granted  permission  to  get  out  of  bed.  Increase  in  the 
number  of  pulse-beats  of,  on  an  average,  from  20  to  30,  and  persistence 
of  the  pulse-curve  at  this  high  level  for  some  time — not  rarely  for  as 
long  as  two  weeks  and  more — is  at  this  time  quite  customary  ;  but  it 
should  be  expressly  stated  that  examination  of  the  heart  throughout 
the  entu'e  continuance  of  this  condition  discloses  no  special  altera- 
tion. 

The  followiug  two  tracings  may  serve  as  characteristic  instances  of  this 
character  of  the  pulse  and  the  temperature.  Fig.  44  represents  such  a  curve 
during  convalescence.  The  case  was  that  of  a  baker's  apprentice,  seven- 
teen years  old,  who  was  free  from  fever  after  the  twenty-eighth  day  of  the 
disease,  and  exhiliited,  with  a  temperature-curve  sul)siding  below  the  normal, 
also  subnormal  pulse-frequency,  with  moderate  instability.  Inmiediately 
after  getting  up  there  set  in,  without  the  temperature  being  influenced 
thereby,  an  unusual  increase  in  the  pulse-frequency,  persisting  for  sixteen 
days.  The  heart  at  the  same  time  remained  conq:»letely  unaffected  both  in 
size  and  action. 

In  the  second  case  (Fig.  45)  the  first  few  days  of  convalescence  still 
exhi])it  a  subnormal  temperature,  with  at  first  an  increased  pulse-frequency. 
With  restoration  of  the  body-temperature  to  the  normal  the  number  of 
pulse-beats  then  sinks  somewhat,  and  fluctuates  morning  and  evening  between 
80  and  85.  Getting  up  on  the  forty-seventh  day  of  the  disease  is  again  fol- 
lowed by  excessive  increase  in  pulse-frequency,  with  conqilete  irregularity  in 
its  curve.  This  condition  persists  for  three  weeks  without  corresponding 
elevation  of  the  body-temperature  or  other  objective  derangement  of  the 
heart,  and  then  slowly  gives  way  to  the  former  normal  conditions. 

That  such  an  unusual  increase  in  pulse-frequency  may  constitute  the 
beginning  of  a  relapse  may  be  again  mentioned,  principally  for  the  purpose 
of  introducing  a  curve  that  especially  illustrates  this  point  (Fig.  46). 


CON  VALESCENCE. 


371 


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372 


TYPHOID  FEVER. 


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CONVA  LESCENCE. 


373 


CHANGES  IN  INDIVIDUAL  ORGANS. 
The  heart  only  exceptionally  exhibits  alterations  during  convales- 
cence. Now  and  again,  undoubtedly  much  less  commonly  than  during 
the  febrile  period,  myocarditis,  with  dilatation  and  corresponding  mani- 
festations of  cardiac  weakness,  occurs  ;  generally,  hoAvever,  the  termination 
is  favorable.  Endocarditis  and  pericarditis  occur  still  more  exceptionally. 
If  they  occur  at  all,  they  are  ahnost  always  referable  to  mLxed  infection, 
especially  to  a  complicatmg  septicemia.  A  result  of  the  conjoint  influ- 
ence of  anemia  and  cardiac  weakness,  which  is  sometimes  manifested 


374  TYPHOID  FEVER. 

during  the  first  portion  of  the  stage  of  convalescence,  is  edema  about  the 
ankles  and  the  legs,  occurring  especial!}-  in  ])revi(»usly  debilitated  persons. 

This  is  to  be  dislinguislied  from  that  unconinion  variety  of  ih-opsicnl 
swelling  of  the  subcutaueous  connective  tif^sue,  which  is  wiclt'ly  (.libtributed 
over  the  entire. body,  and  may  even  be  associated  with  ascites.  Griessinger  ' 
especially  mentions  the  occurrence  of  this  condition,  and  cites  similar  obser- 
vations by  Leudet.  The  cases  are  said  to  be  but  rarely  atteutled  with  all)U- 
minuria,  and  may  occur  entirely  without  this  phenomenon.  Griessinger  has 
no  satisfactory  explanation  for  them.  Personally,  I  have  not  oI)served  this 
symptom-complex  except  in  association  with  coincident  or  shortly  antecedent 
nephritis. 

The  venous  thromboses  previously  described  are  encountered 
with  relative  frequency  during  convalescence,  especially  in  the  veins  of 
the  thigh  and  the  deep  veins  of  the  calves.  They  are  among  those 
symptoms  that  olten  prolong  convalescence  unduly.  Fortunately,  they 
are  rarely  the  source  of  fatal  emboli.  Arterial  thrombosis  with  spon- 
taneous gangrene,  which  is  extremely  rare,  has  likewise  been  previously 
considered  (p.  167). 

In  the  large  majority  of  cases  the  condition  of  the  dig"estive 
organs  rapidly  returns  to  the  normal  soon  after  defervescence.  The 
lips  and  the  tongue  begin  to  clear  even  duruig  defervescence,  so  that 
the  tongue  is  but  slightly  coated  duruig  the  first  few  days  of  convales- 
cence, and  then  especially  in  the  middle  and  posteriorly,  while  the 
margms  and  the  tip  are  free  from  fur.  After  the  tongue  has  become 
completely  clear,  it  often  for  a  considerable  time  appears  thin,  small  and 
red,  and  remarkably  smooth. 

The  appetite,  which  almost  always  returns  with  defervescence,  often 
even  previously,  becomes  the  well-known  voracious  "  appetite  of  con- 
valescence," which  may  be  a  source  of  great  difficulty  for  the  friends 
and  the  physician,  and  readily  of  danger  for  a  disobedient  patient. 
Failure  of  the  appetite  to  return  is  quite  rare,  and  is  worthy  of  special 
consideration.  Except  in  previously  ill  and  reduced  individuals,  this 
phenomenon  is  indicative  of  the  latent  persistence  of  earlier  alterations 
or  is  a  sign  of  impending  complications.  If  associated  with  vomiting 
and  persistence  or  recurrence  of  diarrhea,  sluggish  intestinal  lesions 
must  be  thought  of,  as  sequels  of  which  intestinal  hemorrhage  and 
perforative  peritonitis  have  been  observed,  even  at  a  late  period. 
Sometimes  complete  loss  of  appetite  not  amenable  to  any  measure  gives 
rise  to  the  rare  form  of  t}^hoid  marasmus  previously  described,  which 
persists  until  death  finally  occurs.  In  cases  pursuing  a  regular  and 
benign  course,  the  typhoid  diarrhea  is  likely  to  cease  before  defer ves- 

^  Loc.  cit.,  S.  230. 


CONVA  LESCENCE.  375 

cence  is  completed.  As  a  rule,  moderate  constipation  follows,  which 
occasionally  may  be  extremely  obstinate,  and  then  may  be  associated 
even  with  elevation  of  temperature.  . 

In  rare  cases  disorders  on  the  part  of  the  liver  and  the  biliary 
passag'es  make  their  appearance  as  late  as  the  period  of  convales- 
cence. They  manifest  themselves  especially  l)y  tenderness  over  the 
region  of  the  liver  and  the  gall-bladder,  and  are  in  part  probably 
attributable  to  inflammatory  conditions  dependent  upon  the  almost 
constant  presence  of  typhoid-bacilli  in  the  gall-bladder  and  large 
biliary  passages  of  the  patient  (Gilbert  and  Girode,'  Dupre,^  Chiari,^ 
Birch-Hirschfeld  ■^)  (see  page  209). 

In  the  light  of  these  bacteriologic  findings,  the  observations  recently 
made  by  various  writers  of  the  occurrence  of  biliary  colic  during  con- 
valescence acquire  special  significance.  After  Bemheim  had  suggested 
the  probability,  Gilbert  and  Girode  and  Dupre  demonstrated  by  illus- 
trative cases  that  the  presence  of  the  typhoid-bacillus  in  the  gall- 
bladder might  be  the  direct  cause  for  the  formation  of  calculi.  In  this 
they  were  supported  especially  by  Dufourt,^  who  presented  an  abundance 
of  clinical  evidence,  and  also  by  Milian  ^  and  Hanot.''  Experimental 
proof  for  this  has  also  been  given  by  several  observers  (see  p.  210). 

From  my  own  observations  I  agree  absolutely  with  the  opinion  that 
the  formation  of  gfall-stones  is  by  no  means  a  rare  occurrence  in  the 
period  of  convalescence,  in  spite  of  the  most  recent  contradiction  by 
Chauifard.^  Naturally,  the  formation  of  gall-stones  does  not  always 
make  itself  manifest  as  early  as  the  period  of  convalescence.  The  first 
attack  of  colic  often  enough  occurs  only  subsequently.  That  this  mav 
occur  at  a  very  remote  period  is  shown  by  Hunner's  ^  case,  in  which  the 
attack  occurred  eighteen  years  after  the  attack  of  typhoid  fever.  The 
question  as  to  whether  cholecystitis  and  cholelithiasis  may  be  induced 
by  the  action  of  typhoid-bacilli  independently  of  any  attack  of  typhoid 
fever  has  been  raised  by  Gushing' s  ^^  case  in  which,  from  the  contents  of 
the  gall-bladder,  a  pure  culture  of  typhoid-bacilli  was  obtained,  and  yet 
the  patient  gave  no  history  of  a  previous  attack  of  typhoid  fever.  It  is 
noteworthy  that,  on  obtaining  a  careful  history  of  patients  suffering 
from  gall-stones,  the  fact  of  an  antecedent  attack  of  typhoid  fever,  a 
shorter  or  longer  time  previously,  is  encountered  with  remarkable 
frequency.  < 

1  Compt.  rend,  de  la  soc.  de  biol.^  1890  and  1893. 

'  Gaz.  des  hop.,  1891.  '^  Loc.  cit.  *  Loc.  cif. 

5  Rev.  de  Med..,  1893.  *  Bull,  de  la  soc.  anat.  de  Paris,  Nov.  20,  1896. 

1  Bull,  med.,  June  23,  1896.  s  ^g^.  ^g  Med.,  1897. 

*  Loc.  cit.  ^0  Johns  Hopkins  Hosp.  Bull.,  vol.  is. 


376  TYPHOID  FEVER. 

Anions:  42  cases  treated  for  gall-stones  at  my  clinic  in  recent  years,  there 
were  13,  thus  30.9  per  cent.,  in  which  there  had  been  a  previous  attack  of 
typhoid  fever,  and  symptoms  of  cholelithiasis  had  appeared  definitely  only 
suhsiequently.  Of  these  cases,  the  following  2  may  be  briefly  described  :  A 
woman,  thirty-six  yeai-s  old,  was  received  in  the  clinic  on  August  21,  1891, 
on  account  of  an  attack  of  typhoid  fever.  After  having  been  free  from 
fever  for  almost  four  weeks,  and  in  a  state  of  perfect  convalescence,  she  was 
suddenly  seized  with  several  attacks  of  biliary  colic,  succeeding  one  another 
at  short  intervals,  which  materially  retarded  recovery.  The  second  case 
occurred  in  a  woman,  thirty-eight  years  old,  who  had,  in  INIay,  1890,  passed 
through  an  attack  of  typhoid  fever  of  five  weeks'  duration  at  the  clinic.  In 
the  beginning  of  the  following  year  an  attack  of  biliary  colic  appeared  for 
the  first  time,  and  thereafter  was  repeated  several  times.  After  she  had 
been  admitted  to  the  hospital  in  March,  1894,  on  account  of  severe  pain  in 
the  epigastrium,  radiating  toward  the  right  half  of  the  chest  and  the  back, 
and  associated  with  jaundice,  several  large  gall-stones  and  a  number  of  frag- 
ments were  demonstrated  in  the  stools. 

Of  31  cases  of  cholecystitis  associated  with  gall-stones  treated  at  the 
Johns  Hopkins  Hospital,  10  gave  a  history  of  a  previous  attack  of 
typhoid  fever. 

Also,  in  the  vast  majority  of  cases  the  condition  in  the  respiratory 
organs,  especially  the  lung's,  returns  to  the  normal  toward  the  end  of 
the  febrile  state  or  during  the  first  period  of  convalescence.  The  bron- 
chitis persists  beyond  the  febrile  stage  almost  solely  in  old  or  debilitated 
persons.  Hypostatic  congestion,  however,  if  the  patients  recover,  may 
persist  into  the  first  week  of  convalescence.  Pneumonia  is  quite  rare 
as  a  complication  of  convalescence,  and  pleurisy  still  more  so.  In 
greatly  reduced  individuals,  with  enfeeblement  and  dilatation  of  the 
heart,  pulmonary  infarction  probably  occurs  exceptionally. 

The  relation  of  tuberculosis  to  convalescence  is  noteworthy.  We 
have  seen  that  old,  previously  latent  tuberculous  processes,  or  those 
giving  rise  to  slight  manifestations,  may  suddenly  progress  rapidly 
during  convalescence ;  and  also  may  give  rise  to  new  foci  of  disease  in 
the  form  of  caseous  pneumonia  or  general  miliary  tuberculosis.  For- 
tunately, it  is  rare  for  the  residua  and  sequels  of  typhoid  affections  of 
the  larynx  to  complicate  convalescence,  either  in  the  form  of  simple 
ulceration  of  the  mucous  membrane  or  in  that  of  perichondritic  processes 
and  necrosis  of  cartilage.  Paralysis  of  the  vocal  cords  has  been  excep- 
tionally observed.  As  has  been  pointed  out,  most  of  the  lesions  of  the 
larynx  mentioned  occur  in  the  second  half  of  the  febrile  period.  It 
appears  quite  rare  for  them  to  develop  as  late  as  the  period  of  conva- 
lescence. 

The  alterations  and  symptoms  referable  to  the  nervous  System, 
likewise,  generally  improve  rapidly  during  convalescence,  in  the  great 


CONVALESCENCE.  377 

%• 

majority  of  instances.  Previously  healthy,  not  hysteric  or  neurasthenic, 
persons  acquire  a  peaceful,  quite  contented  frame  of  mind  soon  after 
defervescence.  At  most,  they  distress  themselves  with  desires  with 
reference  to  food,  which  may  not  be  fulfilled,  and  overestimate  their 
functional  ability,  and  in  consequence  are  desirous  of  gettin<^  out  of 
bed  too  early  and  of  resuming  their  work.  Women  and  debilitated 
persons  remain  gloomy,  irritable,  and  even  hypochondriacal  during  the 
first  period.  Children  also  are  likely  to  be  ill-tempered  and  lacrimose 
at  first. 

That  mental  disturbances,  especially  isolated  delusions,  may  persist 
for  a  considerable  time,  and  even  far  beyond  the  period  of  convales- 
cence, has  been  previously  pointed,  out  and  illustrative  instances  have 
been  cited.  However,  it  should  be  noted  that  these  disturbances  per- 
sist from  the  febrile  period  far  more  frequently  than  they  arise  during 
convalescence. 

Headache,  which  plays  no  inconsiderable  role  during  the  initial 
period  of  the  attack  of  typhoid  fever,  is  quite  rare  during  convalescence. 
If  the  patient  is  not  a  person  who  for  a  long  time  preceding  the  attack 
had  suffered  habitually  from  headache,  the  appearance  of  this  symptom 
during  convalescence  should  be  viewed  with  distrust.  Not  rarely  com- 
plications are  concealed  behind  it,  as,  for  instance,  meningeal  inflam- 
mation secondary  to  middle-ear  disease,  sinus-thrombosis,  and  even 
cerebral  abscess.  Quite  exceptionally  following  typhoid  fever  there 
may  also  be  headache,  continuing  for  years,  or  even  throughout  life, 
without  demonstrable  organic  lesion. 

Focal  disease  of  the  brain,  persisting  from  the  febrile  period  into 
convalescence,  and  even  beyond  it,  may,  of  course,  occur.  In  this  con- 
nection monoplegia  and  hemiplegia,  aphasic  states,  and  multiple  sclerosis 
should  be  borne  in  mind.  Among  the  spinal  affections  and  disorders 
of  the  peripheral  nerves,  ataxia  and  pseudo-ataxia,  and  the  compara- 
tively frequent  distressing  neuralgic  disturbances,  especially  in  the  toes 
and  the  heels,  should  be  borne  in  mind. 

Among  the  organs  of  special  sense,  the  ear  almost  solely  plays  any 
role.  Affections  of  the  middle  ear,  with  perforation  of  the  tympanic 
membrane  and  suppuration,  may  make  the  clinical  picture  of  convales- 
cence quite  serious  ;  and,  if  life  is  preserved,  may  give  rise  to  permanent 
impairment  of  hearing.  As  serious  diseases  of  the  eyes  are  far  less 
common  in  the  course  of  typhoid  fever  than  are  diseases  of  the  auditory 
apparatus,  so  during  convalescence  are  they  but  rarely  likely  to  require 
the  intervention  of  the  physician.     Photophobia  during  the  first  week 


378  TYPHOID  FEVEB. 

of  convalescence  in  patients  who  are  sensitive  in  other  respects  is 
comparatively  tlie  most  freqneut  ocular  symptom. 

More  frequent  than  nervous  disorders  during;  the  period  of  con- 
valescence are  alterations  in  muscles,  bones,  and  joints.  In  this 
connection  the  softening  processes,  the  lacerations,  and  the  hemor- 
rhnffes  into  the  substance  of  the  muscles  should  be  borne  in  mind. 
Attention  has  been  called  recently  in  a  number  of  communications  by 
surgeons  to  the  typhoidal  lesions  of  the  bones  and  periosteum.  I  have 
repeatedly  observed  periostitis  with  secondary  necrosis,  as  well  as  osteo- 
myelitis, appear  during  convalescence,  and  prolong  this  unduly.  Such 
lesions  may  eventually  require  operative  intervention,  sequestrotomy, 
and  the  like,  and  may  give  rise  to  even  permanent  impairment  of 
function  of  the  parts  involved.  Less  common,  but  especially  worthy 
of  mention  on  account  of  their  consequences,  are  inflammator}^  disorders 
of  the  joints  arising  during  convalescence.  Eoser  ^  had  already  called 
attention  to  such   involvement  of  the  hip-joint. 

A  more  extended  discussion  of  this  subject  will  be  found  in  the 
section  on  Pathology,  p.  87. 

Of  alterations  in  the  urinary  organs  there  is  not  much  to  say.  The 
polyuria  of  convalescents,  which  in  itself  is  of  little  significance,  and 
only  with  exceptional  rarity  constitutes  the  inception  of  diabetes  insipi- 
dus, has  been  mentioned.  Febrile  albuminuria  persists  but  rarely  to 
the  beginning  of  convalescence ;  the  alterations  in  the  urine  caused  by 
actual  typhoid  nephritis,  however,  may  persist  beyond  the  period  of 
convalescence.  Fortunately,  it  is  an  exceptional  occurrence,  especially  in 
comparison  with  other  acute  infectious  diseases,  as,  for  instance,  scarlet 
fever,  diphtheria,  and  necrotic  angina,  for  chronic  nephritis  to  develop 
from  the  acute.  When  the  lesions  of  the  kidney  actually  persist  beyond 
the  period  of  convalescence,  hope  of  their  subsidence  may  still  be  enter- 
tained for  months  and  even  a  year ;  and  when  subsidence  does  not  take 
place  within  this  time,  a  long-continued,  but  not  violent,  course  may 
with  probability  be  predicted. 

In  women  vesical  catarrh  of  slight  virulence  may  occasionally  occur 
toward  the  end  of  the  febrile  stage,  or  may  first  appear  during  conva- 
lescence. In  men  this  is  extremely  rare,  and  then  almost  always  as  a 
result  of  careless  employment  of  the  catheter. 

However,  the  typhoid-bacilli  may  persist  in  the  urine  for  months 
and  even  for  years  and  may  induce  a  chronic  form  of  cystitis  (see 
p.   190). 

AVith   regard  to  the  genital  functions,   it  should  be  mentioned 

1  Hehviy,  Inaiig.  Diss.,  Marburg,  1856  ;  cited  by  Griessinger. 


CONVALESCENCE.  379 

that  pregnant  women,  after  having  successfully  passed  through  the 
febrile  stage,  not  rarely  abort  or  are  delivered  prematurely  during 
convalescence. 

Menstruation  returns  in  a  most  variable  manner.  In  vigorous,  robust 
women,  but,  unfortunately,  sometimes  also  in  already  highly  anemic 
ones,  it  occasionally  returns  soon  after  defervescence — in  small  amount, 
as  a  rule,  for  the  first  few  times ;  occasionally,  however,  so  profusely 
that  the  patient  is  thereby  seriously  injured  and  retarded  in  the 
progress  toward  recovery.  In  other  cases,  on  the  contrary,  without 
special  causes  being  discoverable  therefor,  menstruation  long  remains 
absent,  even  for  many  months  beyond  convalescence.  Also,  menstrual 
molimina  previously  not  noticeable  are  considered  by  women,  at  times 
correctly,  as  a  sequel  of  the  attack  of  typhoid  fever.  Peri-uterine 
hematocele,  described  by  Trousseau,  and  hematometra,  which  occurs 
rarely,  with  its  often  obstinate  sequels,  have  been  referred  to  (p.  196). 
Sometimes  the  residua  of  inflammation  of  the  glands  of  Bartholin  and 
decubital  ulcers  of  the  labia  and  the  vulva  cause  much  discomfort 
during  convalescence. 

In  men,  at  the  period  of  adolescence,  erections  again  occur  during 
early  convalescence,  and  in  addition  not  rarely  distressing  enervating 
pollutions.  For  some  patients  they  constitute  directly  a  disturbing 
complication  at  this  time.  Orchitis  and  epididymitis  are,  as  is  well 
known,  quite  rare,  and  then  are  generally  affections  of  the  last  part  of 
the  febrile  stage.  Among  6  cases  under  my  personal  observation,  2 
developed  after  defervescence. 

The  skin  is  generally  dry  at  the  beginning  of  convalescence,  and 
when  it  has  been  indurated  and  thickened,  particularly  on  the  hands 
and  the  feet,  it  is  desquamated  at  this  time  in  shreds  of  greater  or  lesser 
size.  On  the  trunk,  and  especially  on  the  abdomen,  branny  desqua- 
mation of  the  epidermis  often  occurs  if  there  has  been  an  extensive 
sudaminal  eruption  during  the  febrile  stage.  This  desquamation  at 
times  becomes  so  marked,  particularly  in  children,  that  if  the  patients 
first  come  under  observation  during  convalescence,  serious  doubt  may 
arise  as  to  the  nature  of  the  antecedent  disease.  Multiple  furunculosis, 
which  formerly  constituted  so  distressing  a  disturbance  of  convalescence 
for  patient  and  physician  alike,  is,  fortunately,  at  the  present  day  far 
less  common  than  at  the  time  when  unnecessarily  frequent  and  too  cold 
baths  were  prescribed.  Bed-sores  also  by  no  means  play  the  same  role 
as  formerly.  With  regard  to  the  condition  of  the  hair  and  the  nails 
during  convalescence,  reference  may  be  made  to  pages  132  and  133. 


380  TYPHOID  FEVER. 

THE  DURATION  OF  CONVALESCENCE. 
Convalescence,  which  begins  -vvith  the  close  of  the  febrile  period, 
cannot  have  its  total  duration  accurately  estimated,  because  definite 
criteria  of  its  termination  ciinuot  be  established.  In  general  it  may  be 
considered  as  ended  when  the  nutrition  has  been  so  far  improved  that 
the  body-weight  approximates  its  previous  level,  and  the  individual 
is  free  from  complaints  and  is  again  capable  of  resuming  his  work.  If 
the  time  mcluded  in  this  period  be  observed  in  a  large  number  of 
cases,  its  Icngtli  will  be  fomid  to  be  extremely  variable.  An  important 
ro/e  is  played  in  this  connection,  naturally,  by  the  severity  of  the  ante- 
cedent disease,  but  age,  sex,  constitution,  and  complications  are  also  of 
such  importance  that  cases  originally  of  mild  course  may  be  attended, 
in  consequence  of  the  influence  of  these  factors,  with  extremely  pro- 
tracted convalescence.  AVe  may  recall,  m  this  connection,  the  course 
of  t}'phoid  fever  in  the  aged,  and  the  afebrile  and  slow  forms.  The 
probable  duration  is,  naturally,  beyond  the  range  of  estimation,  in  the 
presence  of  complications  and  sequels,  as  weU  as  in  cases  attended  with 
recrudescences  and  relapses.  Apart,  however,  from  individual  condi- 
tions, extraneous  circumstances  still  difficult  of  appreciation  at  the 
present  day  may  in  the  course  of  certain  epidemics  cause  convalescence 
in  general  to  be  protracted.  If  it  be  desired  to  express  the  duration  of 
convalescence  definitely  in  figures,  a  period  of  from  two  to  three  weeks, 
after  well-marked,  uncomplicated  cases,  may  be  considered  as  short  and 
favorable.  Scarcely  less  common,  and  quite  usual  after  severe  attacks, 
is  a  duration  of  from  four  to  five  weeks.  In  not  a  few  cases  convales- 
cence may  be  protracted  even  beyond  this  period,  and  occasionally  is 
of  extraordinaiy  duration,  particularly  in  relapsing,  slow,  or  marantic 
cases. 

In  Leipsic  (Berg)  the  average  duration  of  convalescence  was :  Up  to 
twenty  days,  in  55  per  cent,  of  all  oases ;  twenty  to  forty  days,  in  39  per 
cent.  ;  forty  to  sixty  days  and  <wer,  in  5.8  per  cent. 

An  analysis  of  1'096  ?ases  during  the  severe  epidemic  at  Hamburg  in 
1886-1887  disclosed  a  duration  of  up  to  twenty  days  in  319  cases — 10.3 
per  cent. ;  between  twenty-one  and  forty  days  in  2447  cases — 79  per  cent.  ; 
between  forty-one  and  sixty  days  in  211  cases — 6.8  per  cent.  ;  sixty-one  days 
and  over  in  119  cases — 3.8  per  cent. 

THE  TOTAL  DURATION  OF  THE  DISEASE. 

It  will  be  most  appropriate  at  this  place  to  make  some  additional 
remarks  concerning  the  total  duration  of  the  disease,  which,  naturally, 
includes  both  that  of  the  febrile  period  and  that  of  convalescence. 
In  the  first  place,  some  statements  may  be  added  with  regard  to  the 


THE  TOTAL  DURATION  OF  THE  DISEASE.  381 

duration  of  the  febrile  stage.  It  is  incomparably  more  difficult  to  give 
an  average  figure  for  this  stage  in  typhoid  than  in  the  acute  infectious 
diseases  that  pursue  a  far  more  cyclic  course,  as,  for  instance,  fibrinous 
pneumonia,  typhus  fever,  relapsing  fever,  and  the  acute  exanthemata. 
While  in  the  latter  the  fever  is  confined  to  sharj^ly  defined  time-limits, 
the  febrile  stage  of  typhoid  fever  is,  as  has  been  seen,  of  infinitely  varia- 
ble course  and  duration,  from  cases  that  become  afebrile  in  the  course 
of  a  few  days,  to  those  lasting  many  weeks.  In  addition,  the  propor- 
tionate frequency  of  the  mildest  cases,  the  moderately  severe,  the  severest, 
and  those  of  longest  duration,  is  extremely  variable  at  different  times 
and  in  different  places.  The  frequency  of  the  mild  and  abortive  cases 
is  especially  variable.  This  is  not  even  proportional — as  must  again 
be  especially  emphasized — ^to  the  severity  or  the  mildness  of  the  char- 
acter of  the  individual  epidemic  in  other  respects.  Thus,  I  have 
encountered  periods  in  which,  in  spite  of  a  relatively  large  number,  of 
mild  and  abbreviated  cases,  the  mortality  was  quite  considerable,  because 
the  severe  well-marked  cases  pursued  an  especially  unfavorable  course 
under  the  controlling  influence  of  the  predominating  varieties  of  course 
and  complications.  If  the  indeterminate  mild  and  abbreviated  cases 
be  left  out  of  the  count,  and  an  attempt  is  made  to  determine  the  dura- 
tion of  the  well-marked  moderately  severe  and  severe  cases  only,  the 
average  duration  of  the  febrile  period  will  be  found  to  be  from  two  and 
a  half  to  five  weeks,  but  this  may  be  extended  to  six  weeks  and  even 
beyond,  even  in  the  absence  of  complications. 

It  may  be  instructive  to  form  an  idea  of  the  variable  duration  of  all 
the  cases  in  a  single  epidemic,  the  mild  and  the  severe  together.  Thus,  an 
analysis  of  the  cases  at  Hamburg  in  the  year  1886—1887  yielded  the  fol- 
lowing results  :  The  duration  of  the  febrile  period  was  observed  to  be  up  to 
twenty-one  days  in  2040  cases — 57.1  per  cent.  ;  from  twenty-two  to  thirty- 
three  days  in  1118  cases — 31.3  per  cent.  ;  thirty-three  days  and  over  in 
417  cases — 11.6  per  cent.  In  9  instances  the  duration  was  more  than  sixty 
days,  and  the  longest  was  seventy-five  days. 

With  regard  to  the  conditions  responsible  for  the  duration  of  the 
fever,  as  little  is  known  as  with  regard  to  the  circumstances  responsible 
for  the  various  forms  in  general.  Even  the  general  factors  are  but  little 
known.  The  influence  of  age,  however,  is  the  most  conspicuous  of 
these  factors.  We  have  already  seen  that  the  febrile  stage  in  children 
is  in  general  shorter  than  that  in  adults,  and  that  during  childhood 
itself  this  is  true  of  the  early  periods  in  greater  degree  than  of  the  later. 
The  course  of  the  disease  is  especially  prolonged  after  the  fortieth  year 
and  in  old  age. 

An  examination  of  our  statistics  at  Hamburs:  with  resrard  to  the  duration 


382 


TYPHOID  FEVER. 


of  the  fever  at  the  various  periods  of  life  (estimated  with  reference  to  the 
number  of  cases  admitted  at  the  various  age-periods)  yielded  the  following 
results  : 


Age. 

Duration  of  febrile  period. 

Up  to  21  days. 

From  22  to  33  days. 

33  days  and  over. 

2  to    5  years 

G  to  10     "        

11  to  14     "        

15  to  20     "        

21  to  25     "        

2G  to  30     "       

31  to  35     "       

30  to  40     "       

41  to  45     "       

92.0 
71.0 

60.8 
53.4 
57.3 
51.8 
52.4 
44.1 
41.9 

4.0 

18.G 
25.7 
32.5 
31.2 
31.0 
31.9 
33.3 
29.6 

2.0 
7.7 
11.8 
11.5 
9.8 
12.1 
11.9 
16.5 
28.4 

This  table  concludes  with  the  forty-fifth  year,  as  the  number  of  cases 
admitted  at  later  age-periods  is  naturally  so  small  that  they  do  not  appear 
available  for  statistical  purposes. 

The  difficulty  of  obtaining  a  general  numerical  idea  as  to  the  total 
duration  of  the  disease — that  is,  from  the  beginning  of  the  fever  to  the 
termination  of  convalescence — need  not,  in  view  of  the  foregoing,  again 
be  pointed  out.  Nevertheless,  a  few  suggestive  figures  may  be  useful. 
For  well-marked  cases  of  typhoid  fever  I  should  consider  the  average 
duration  from  the  beginning  to  the  period  of  discharge  and  restoration 
of  the  capability  for  work  as  from  five  to  ten  weeks.  Only  the  atypi- 
cal and  the  milder  cases  run  their  course  within  a  shorter  period. 
Not  a  few  cases,  however,  persist  for  a  considerable  time  beyond  the 
average  period  stated.  I  have  observed  extreme  cases,  which,  never- 
theless, terminated  in  complete  recovery,  last  up  to  twenty  weeks, 
exceptionally  for  a  half-year,  and  even  longer.  In  the  latter  cases,  of 
course,  the  prolongation  was  dependent  upon  the  influence  of  local 
lesions  and  upon  recrudescences  and  relapses. 

Of  more  than  3000  carefully  studied  cases  in  the  epidemic  at  Hamburg, 
72.5  per  cent,  had  a  total  duration  of  from  thirty -one  to  eighty  days.  The 
average  duration  of  all  the  analyzed  cases  was  fifty-five  days. 

FATAL  TERMINATION.     PROGNOSIS. 

With  regard  to  the  prognosis  of  the  non-fatal  cases,  abundant  refer- 
ences have  been  made  at  many  parts  of  this  work,  so  that  the  following 
section  will  confine  itself  almost  exclusively  to  tlie  fatal  termination  and 
the  related  prognostic  considerations.  With  regard  to  the  frequency 
of  a  fatal  termination  in  general,  definite  statistics  are  not  readily  attain- 
able. Although  a  mortality  of  from  5  to  6  per  cent.,  on  the  one  hand, 
and  of  30  or  even  40  per  cent.,  on  the  other  hand,  is  mentioned,  it  may 


FATAL   TERMINATION.      PROGNOSIS.  383 

be  stated  at  the  outset  that  such  extremes  are  attributable  to  quite 
definite  conditions.  Leaving  these  groups  of  cases  out  of  consideration^ 
the  general  mortality  is  stated  by  the  earlier  classical  writers  tfj  be 
between  18  and  20  per  cent.  According  to  modern  experience,  how- 
ever, it  is  distinctly  lower,  namely,  from  9  to  12  per  cent.,  and  at  most, 
14  per  cent.  Inquiry  as  to  the  causes  for  this  reduction  in  mortality 
will  show  that  it  is  due  in  part  to  improvement  in  special  methods  of 
treatment  and  in  the  general  hygienic  conditions,  and  possibly  also  to 
a  reduction  in  the  virulence  of  the  disease,  in  favor  of  which  is  the  evi- 
dence which  is  available  with  regard  to  the  behavior  of  other  infectious 
diseases  in  this  respect.  A  more  important  influence,  however,  than 
these  factors  in  reducing  the  present  mortality  resides  in  the  perfection 
of  diagnosis,  so  that  a  large  number  of  cases  previously  not  considered 
as  typhoid  fever,  which  unexceptionally  terminate  in  recovery,  are  now 
recognized  as  examples  of  this  disease.  This  circumstance  is  taken 
account  of  also  by  a  number  of  earlier  writers,  who,  in  estimating  the 
mortality,  excluded  the  mild  cases  at  the  outset. 

Thus,  Griessinger  deducts  from  510  cases  of  typhoid  fever  40  of  mild, 
febricular  character,  and  estimates  the  mortality  of  the  remaining  470  at 
18.8  per  cent.  Murchison  arrives  at  approximately  the  same  figures.  He 
found  among  2505  cases  in  the  London  Fever  Hospital  for  the  years  1848- 
1862  a  mortality  of  18.5  per  cent.  That  his  and  Griessinger' s  results  were 
the  expression  of  the  general  mortality-rate  in  typhoid  fever  at  that  time  is 
indicated  by  the  result  of  an  investigation  of  18,612  collected  cases  (from 
London,  Glasgow,  Paris,  Strassburg,  and  the  French  provinces)  of  the  fifth, 
sixth,  and  the  beginning  of  the  seventh  decade  of  the  nineteenth  century, 
which  likewise  yielded  a  mortality-rate  of  18.52  per  cent.  The  conditions 
at  Vienna  were  remarkably  more  unfavorable  during  the  same  period.  In 
the  Vienna  General  Hospital  there  were  observed  between  1846  and  1861 
21,189  cases  of  typhoid  fever  with  4708  deaths — 22.2  per  cent. 

These  figures  may  be  compared  with  some  of  more  recent  date ;  there 
were  treated  in  the  Jakobsspital  of  Leipsic,  from  1880  to  1893,  1626  cases 
of  typhoid  fever,  of  which  243 — 12.7  per  cent. — terminated  fatally.  Earher 
statistics  by  Uhle  from  the  same  hospital  showed  that  600  patients  exhibited 
the  average  mortality  at  that  time  of  18.5  per  cent.  In  the  epidemic  of 
1886-1887  at  Hamburg,^  the  mortality-rate  was  comparatively  favorable. 
Of  10,823  patients  throughout  the  entire  city,  840  died — 8.5  per  cent. 
They  were  distributed  throughout  the  two  years  as  follows  :  1886,  3948  cases, 
with  364  deaths— 9.2  per  cent.  ;  1887,  6875  cases,  with  476  deaths— 6.9  per 
cent. 

Of  the  3686  patients  of  this  group  treated  in  the  hospital,  the  mortality 
was  somewhat  higher — 362  (9.8  per  cent.) — undoubtedly  on  account  of  the 
smaller  number  of  mild  cases.  As  compared  with  these,  the  statistics  of 
Thiingel  are  interesting,  who  observed  among  504  patients  in  the  same  hospital, 
between  the  years  1858  and  1861,  96  deaths — 19  per  cent.  Finally,  I  would 
state  further  that  a  study  of  3600  cases  that  I  treated  personally  during  the 

^  Bericht  des  Hamburger  Medicinalbureaus. 


384  TYPHOID  FEVER. 

period  from  1877  to  1897  iu  various  places  (Berlin,  Hamburg,  Leipsic) 
exhibited  a  total  mortality  of  9.3  per  cent. 

Dui-ing  the  ten  years,  1889  to  1899,  of  829  cases  treated  iu  the  Johns 
Hopkins  Hospital,  Go  died — a  mortality-rate  of  7.5  per  cent. 

It  lias  been  jwintcd  out  that  the  figtires  oiveu  can  be  a])plicable  only 
in  a  general  way..  They  vary  imder  diverse  conditions,  partly  indi- 
vidual, })artly  general,  not  directly  relating  to  the  patient.  It  is  well 
known  that  the  mortality  varies  widely  during  different  epidemics 
and  endemics,  just  as  the  character  and  the  ])eculiarities  of  the  disease 
may  exhibit  great  variations  in  detail  at  different  times. 

The  extent  to  which  climate  and  season  are  operative  in  this  con- 
nection appears  to  be  not  yet  sufficiently  determined,  althougli  Murchison 
believed  that  from  a  study  of  the  statistics  of  the  London  Fever  Hospi- 
tal he  was  able  to  make  out  a  greater  mortality  from  typhoid  fever  in 
the  spring.  Geographic  and  racial  differences  are  insignificant 
in  their  influence  upon  the  mortality.  As  typhoid  fever  is  distributed 
over  almost  all  parts  of  the  world  and  countries,  so  its  virulence  appears 
to  be  everywhere  approximately  the  same.  Where  distinct  differences 
with  regard  to  the  mortality,  particularly  in  an  unfavorable  direction, 
are  apparent,  these  depend  especially  upon  combinations  with  other 
severe  morbid  states  of  local  origin.  An  illustration  of  this  is  afforded 
by  malarial  regions.  Incomparably  better  known  and  more  important 
than  these  general  factors  is  the  influence  of  personal  conditions  upon 
the  mortality.  It  appears  from  previous  statements  that  age  is  of 
greatest  importance  in  this  connection.  The  danger  from  the  disease 
increases  rapidly  Avith  advancing  years.  As  early  as  after  the  fortieth, 
and  particularly  after  the  fiftieth,  year  the  malignancy  of  the  course  is 
great,  while  it  is  undeniably  least  in  children  between  the  second  and 
the  tenth  year.  In  the  later  years  of  childhood,  and  in  the  subsequent 
age-periods  in  adults,  up  to  the  middle  of  the  fourth  decade,  the  differ- 
ences in  the  mortality  and  the  rapidity  of  its  increase  with  advancing 
years  are  less  significant,  but,  on  study  of  a  large  number  of  cases,  they 
are,  nevertheless,  distinctly  appreciable.  Thus,  for  the  periods  from  twenty- 
five  to  thirty  years  and  from  thirty  to  forty,  the  prognosis  is  distinctly 
more  unfavorable  than  In  the  period  from  twelve  to  twenty-five  years. 

The  figui-es  of  most  writers  agree  with  those  given  in  the  table  on 
p.  385.  Thus,  Liebermeister,  among  1743  cases,  during  1865  to  1870, 
found  a  mortality  of  30  per  cent,  for  the  age-periods  above  forty  years  ;  while 
in  those  below  it  was  only  11.8  per  cent.  Uhle,^  at  the  clinic  of  Wuuderlich, 
observed  death  occur  in  moi'e  than  half  of  the  cases  in  patients  above  the 
age  of  forty  years.     Griessinger  utilizes  these  facts  for  an  interesting  explana- 

1  Arch.  f.  phyfiiol.  HcUk.,  1859. 


FATAL   TERMINATION.     PROGNOSIS. 


385 


tion  of  certain  striking  differences  in  the  mortality  in  different  hospitals. 
While  he  lost  18.8  per  cent,  of"  his  patients  in  Zurich,  among  whom  those  in 
the  age-period  above  forty  years  iiinnbered  12.9  per  cent.,  Fiedler,  in  Dres- 
den, with  only  3.1  per  cent,  of  the  latter,  had  a  mortality  of  only  18.1  per 
cent.     The  tracing  (Fig.  47)  is   especially  instructive,  in  which  Fiedler ' 


Age 

Under 
10 

n-ts 

IC-2V 

21-2; 

20-30 

3i-3S 

3G-M 

il-JUi 

f^SO 

ot-aa 

BC-CO 

and 
Clover 

col. 

r 

/ 

/ 

/ 

hoi 

/ 

/ 

/ 

' 

30% 

, 

i 

/ 

/ 

7 

S0%' 

/ 

/ 

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/ 

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^ 

1 

\ 

/ 

10% 

/ 

\/ 

/ 

/ 

^y 

0% 

^ 

->*  - 

/ 

jl 

*> 

Fig.  47. 


presents  the  percentage-relation  of  the  deaths  from  typhoid  fever  to  the  total 
number  of  cases  of  typhoid  fever,  and  their  relation  to  age-periods,  from  the 
material  of  the  Dresden  City  Hospital  during  thirty-four  years  (1850-1883). 
The  relation  of  age  to  the  mortality  is  exhibited  by  the  following  table 
prepared  from  the  Hamburg  statistics  for  the  years  1886-1887  : 


Number  of  cases. 


Deaths. 


Percentage. 


1  to    5  years 

6  to  10     ' 

11  to  14     ' 

15  to  20     ' 

21  to  25     ' 

26  to  30     ' 

31  to  35     ' 

36  to  40     ' 

41  to  45     ' 

46  to  50     ' 

51  to  55     ' 

56  to  60     ' 

50 

156 

245 

1100 

992 

602 

269 

127 

81 

26 

13 


2 
10 
20 

96 

77 

74 

31 

19 

15 

7 

3 

3 


4.0 
6.4 

8.2 
8.7 
7.7 
12.3 
11.5 
14.9 
18.5 
26.9 
23.0 
37.3 


The  differences  in  prognosis  dependent  upon   sex  are,  in  contra- 
distinction to  those  due  to  age,  very  slight.     The  little  difference  that  is 

1  Separatahdruck  aus  den  Berichten  der  Gesellschaft  f.  Nati/r-  und  Hdlkicnde  zu, 
Dresden,  1884.       This  valuable  publication,  which  eontains  a  large  amount  of  carefully 


studied  statistical  data,  is  much  too  little  known. 
25 


386  TYPHOID  FEVER. 

apparent  in  this  connection  is  due  in  men  rather  to  external  and  social 
conditions  (occupation,  mode  of  life,  alcoholism) ;  while  in  women  the 
sexual  functions  are  directly  of  influence,  particularly  pregnancy,  partu- 
rition, and  the  puerperium.  If  an  especially  large  number  of  women 
are  accidentally  received  into  a  hospital  in  consequence  of  external 
conditions,  these  factors  may  be  of  considerable  influence  upon  the 
mortality  if  the  patients  are  largely  at  the  period  of  adolescence.  Under 
oidinaiy  circumstancas  the  differences  in  morbdity  between  the  two 
sexes  are  so  slight  that  they  can  be  almost  entirely  ignored.  It  is 
highly  characteristic  in  this  connection  that,  m  the  course  of  an  epidemic 
of  typhoid  fever  of  considerable  duration,  the  mortahty  among  men  may 
at  times  exceed  that  among  women,  and  vice  versa.  Thus,  at  Hamburg 
in  the  year  1<S86  the  mortality  among  men  (8.5  per  cent.)  was  greater 
than  among  women  (3.5  per  cent.) ;  while  in  the  year  1887  that  among 
women  (9.4  per  cent.)  slightly  exceeded  that  among  men  (8.8  per  cent.). 
It  is  not  worth  while  to  present  here  many  statements  of  other  writers. 
AVith  a  few  exceptions  they  reach  like  results.  Almost  exactly  the 
same  mortality  is  shown,  for  instance,  in  the  following  table  by  Mur- 
chison,  including  1820  cases  of  typhoid  fever  treated  in  the  London 
Fever  Hospital  between  the  years  1848  and  1857  : 

Admissions.  Deaths.  Percentage. 

Males 905  160  17.68 

Female.*      ^15  J73  J^89 

Total 1820  333  18.29 

This  table  may  be  followed  by  one  of  Beetz,  from  the  Munich  medi- 
cal clinic,  including  the  cases  of  typhoid  fever  between  the  years  1874 
and  1877,  and  exhibiting  a  marked  preponderance  of  the  mortality  in 
men.  Probably  we  have  here  an  illustration  of  the  influence  of  certain 
injurious  habits  of  life  in  men  (alcoholic  excess,  particularly  of  beer). 

Mortality — Percentage. 


MUNICH. 

Males. 

Females. 

Total. 

1874  .    .    . 

.    .    .               8.4 

4.7 

6.7 

1875.    .    . 

.    .    .              12.7 

8.5 

10.5 

1877  .    .    . 

.    .    .              13.0 

7.5 

9.9 

Also,  the  social  position  and  the  occupation  are  not  of  so  much 
significance  with  regard  to  the  prognosis  in  typhoid  fever  as  with  regard 
to  that  in  other  infectious  diseases,  as,  for  instance,  typhus  fever.  I 
believe  that  typhoid  fever  has  as  little  relation  to  wealth  and  poverty  as 
to  special  occupations.  It  is  not  even  apparent  that  an  indigent  mode 
of  life  is,  in  itself,  injurious.     On  the  contrary,  the  mode  of  life  of  the 


FATAL   TERMINATION.      PROGNOSIS.  387 

rich  is  almost  more  frequently  to  bo  taken  into  consideration  as  an  inju- 
rious predisposing  factor.  Whether  the  occupations  that  favor  infection 
with  typhoid  fever  in  somewhat  greater  degree  (see  Eti(jl(jgyj  are  to  he 
considered  more  unfavorable  also  from  the  prognostic  standpoint  is 
exceedingly  doubtful. 

In  certain  superficial  respects  the  well-to-do  classes,  it  is  true,  appear 
to  be  somewhat  more  favorably  situated.  They  are,  in  general,  able  to 
secure  more  careful  nursing  and  attendance,  and,  above  all,  come  under 
treatment  early.  The  resulting  advantages  to  the  physician  in  his  daily 
routine  are  in  my  experience  also  appreciable  in  the  hospital,  since  here 
the  prognosis  of  the  cases  which,  by  reason  of  unfavorable  circumstances, 
are  received  exceedingly  late,  is  generally  far  more  grave  than  that  of 
the  cases  admitted  at  an  early  stage.  A  not  inconsiderable  influence  is 
exerted  upon  the  prognosis  by  the  constitution  and  the  condition  of 
general  health  present  before  the  attack  of  typhoid  fever.  With 
regard  to  the  constitution,  the  danger  is  from  the  outset  least  in  young, 
muscular,  spare  persons,  the  so-called  tough  individuals ;  while,  as  has 
been  mentioned,  the  prognosis  must  be  made  with  great  caution  in  the 
case  of  obese  persons,  even  young  ones,  men  as  well  as  women.  That, 
in  addition,  anemic  and  chlorotic  persons  are  exposed  to  great  danger ; 
that  in  alcoholics,  persons  addicted  to  morphin,  and  those  reduced  by 
excesses  in  other  directions,  the  outlook  is  unfavorable,  need  scarcely  be 
emphasized.  Among  the  excesses  physical  and  mental  overexertion  are 
also  to  be  included,  as  well  as  profound  emotional  disturbances,  great 
grief,  and  anxiety.  Among  chronic  diseases,  gout,  diabetes,  heart 
disease,  nephritis,  chronic  disease  of  the  respiratory  organs,  particularly 
advanced  tuberculosis,  are  to  be  considered  as  especially  unfavorable. 

TIME  OF  DEATH. 
The  early  or  late  occurrence  of  death  depends  in  the  individual  case 
especially  upon  the  age  and  the  constitution  of  the  patient,  upon  the 
special  form  of  the  disease,  upon  the  distribution  of  the  typhoid  process 
in  the  various  organs,  as  well  as  upon  the  number  and  the  character  of 
the  complications.  Reference  will  be  made  later  to  a  number  of  espe- 
cially important  points  in  this  connection.  It  is,  however,  not  without 
value  to  obtain  general  figures  with  regard  to  the  time  of  the  fatal  ter- 
mination. The  largest  number  of  deaths  in  average  epidemics  of  ordi- 
nary character  occurs  between  the  second  half  of  the  second  and  the  end 
of  the  fourth  week.  Death  is  much  less  common  at  an  earlier  period. 
It  occurs  even  with  distinctly  greater  frequency  after  the  thirtieth  than 
before  the  tenth  day.     It  is  noteworthy  and  in  accordance  with  the 


388  TYPHOID  FEVER. 

relative  brevity  of  the  course  of  the  disease  in  children  that  the  largest 
number  of  deaths  in  them  occurs  between  the  tenth  and  the  twenty- 
tirst  day.  The  special  character  of  some  epidemics  is  manifested  by,  in 
addition  to  other  features,  a  remarkably  eiu'ly  period  for  the  occurrence 
of  death.  These  epidemics  are  characteiized  by  tlie  frequent  occurrence 
of  profoimd  intoxication  or  especially  early  intestinal  hemorrhage.  It  is 
of  practical  importance  to  note  that  death  may  occur,  and  by  no  means 
rarely,  long  after  the  termination  of  the  febrile  stage.  Marasmus, 
sluggish  processes,  and  sequels  play  an  important  role  in  this  connection. 
I  have  observed  death  occur  as  late  as  the  one  hundred  and  twentieth 
day. 

Our  Leipsic  tables  show  a  fatal  termination  in  the  eleventh  week  in  4 
cases,  and  the  Hamburg  statistics  show  26  cases — 7.7  per  cent. — in  which 
death  occurred  after  the  fiftieth  day.     Both  tables  are  herewith  appended. 

Death  occurred  at  Leipsic  in  the  first  week  of  the  disease  in  6  cases — 
2.5  per  cent.;  second  week,  37  cases — 15.1  per  cent.  ;  third  week,  63  cases 
— 25.9  per  cent.  ;  fourth  week,  51  cases — 20.9  per  cent.  ;  fifth  week,  22 
cases — 9  per  cent.  ;  sixth  week,  20  cases — 8.27  per  cent.  ;  seventh  week,  9 
cases — 3.7  per  cent.  ;  eighth  week,  7  cases — 2.9  per  cent.  ;  ninth  week,  5 
cases — 2.1  per  cent.  ;  tenth  week,  2  cases — 0.82  per  cent.  ;  eleventh  week, 
4  cases — 1.6  per  cent. 

Death  thus  occurred  between  the  second  and  the  fourth  week  in  151 
cases — 62.1  per  cent. 

At  Hamburg,  among  362  cases  of  typhoid  fever,  death  occurred  between 
the  sixth  and  the  tenth  day  in  11  cases — 3  per  cent.  ;  eleventh  and  the 
fifteenth  day  in  51  cases — 14.1  per  cent.  ;  sixteenth  and  the  twentieth  day 
in  68  cases — 16  per  cent.  ;  twenty -first  and  the  twenty-fifth  day  in  46  cases — 
12.4  per  cent.  ;  twenty-sixth  and  the  thirtieth  day  in  45  cases — 12.4  per 
cent.  ;  thirty-first  and  the  fortieth  day  in  35  cases — 11.4  per  cent.  ;  forty- 
first  and  the  fiftieth  day  in  21  cases — 5.8  per  cent.  ;  after  the  fiftieth  day  in 
28  cases — 7.7  per  cent.  From  this  it  follows  that  in  more  than  half  of  the 
cases — i.  e.,  210  (58  per  cent.) — death  occurred  between  the  eleventh  and 
the  thirtieth  day. 

According  to  most  observers  and  my  own  experience,  the  prognosis 

of  relapses  is  in  general  more  favorable  than  that  of  primary  attacks 

and  of  recrudescences.     Of  the  cases  of  typhoid   fever  with  relapse  at 

Hamburg,  I  observed  death  in  4.9  per  cent. 

CAUSE  OF  DEATH. 
The  causes  of  death  in  detail  have  previously  been  somewhat  discussed 
(see  the  chapters  on  Symptomatology  and  on  Course  and  Termination). 
With  regard  to  many  points,  therefore,  reference  must  be  made  to  them. 
Death  results,  on  the  whole,  in  one  of  three  ways.  In  the  first  place, 
in  consequence  of  the  severity  or  the  special  character  of  the  intoxica- 
tion ;  next,  in  connection  with  unusual  development  and  severe  course 
of  the  peculiar  localizations  of  the  disease,  especially  in  the  intestine,. 


FATAL  TERMINATION.     PROGNOSIS.  389 

the  respiratory  organs,  the  nervous  system,  and  the  kidneys  ;  and  finally, 
in  consequence  of  the  seat  and  the  severity  of  the  actual   complications. 

The  severity  of  the  intoxication  is  probably  the  most  important  of 
the  causes  of  death.  From  30  to  50  per  cent,  of  the  deaths  are,  in  my 
experience,  to  be  attributed  to  it.  In  a  larger  sense  the  cases  that  pursue 
a  fatal  termination  with  the  clinical  picture  of  the  hemorrhagic  diathesis 
and  of  hyperpyrexia  may  also  be  included  in  this  category.  The  pro- 
found toxic  effects  are  exhibited  especially  and  most  conspicuously, 
and  often  simultaneously,  by  the  central  nervous  system,  the  heart,  and 
the  vessels.  Cases  that  are  early  attended  with  jjrofound  delirium  or 
derangement  of  consciousness,  in  which  coma,  floccitation,  subsultus 
tendinum,  choreiform  and  spasmodic  states  early  occur,  are  illustra- 
tive of  the  especial  severity  of  the  toxic  action  upon  the  central  ner- 
vous system.  Among  such  manifestations  are  often  included  also 
rigidity  of  the  neck  and  the  back  and  hyperesthesia.  It  may  be  noted, 
however,  that  these  features  may  be  early  and  marked  also  in  cases  that 
subsequently  pursue  a  favorable  course.  On  the  other  hand,  they  may 
be  the  symptoms  of  actual  complicating  meningitis. 

Although,  without  doubt,  constitution,  sex,  age,  and  individual  cir- 
cumstances occasion  a  variable  susceptibility  on  the  part  of  the  central 
nervous  system,  it  may  be  stated  in  general  that  the  prognosis  is  the 
more  unfavorable  the  more  profound  are  the  symptoms  referable  to  the 
central  nervous  system,  and  the  earlier  they  appear. 

Liebermeister  made  an  interesting  analysis  of  his  patients  in  the  epi- 
demic at  Basle  between  1865  and  1868  with  reference  to  this  point,  and 
found  that  of  those  who  exhibited  no  striking  cerebral  symptoms  during  the 
course  of  the  disease,  8.5  per  cent,  died,  while  the  mortality  in  those  patients 
in  whom  only  slight  conditions  of  excitement,  of  short  duration,  or  occurring 
only  during  the  night,  had  existed,  was  19,8  per  cent.  Of  the  cases  with 
marked,  furious,  or  with  muttering  delirium,  54  per  cent,  terminated  fatally, 
while  those  attended  with  sopor  and  coma  exhibited  the  enormous  mortality 
of  70  per  cent. 

With  regard  to  the  effects  of  the  toxins  upon  the  circulatory  organs, 
the  disturbances  that  occur  in  these  are  also  undoubtedly  to  be  con- 
sidered the  more  serious  the  earlier  they  occur  and  the  more  severe 
they  are.  They  are  usually  included  under  the  general  designation 
cardiac  weakness.  It  is  certain,  however,  that  in  cases  of  typhoid  fever 
and  of  other  infectious  diseases  disorders  of  the  vasomotors,  as  has  been 
pointed  out,  play  just  as  important  a  role  as  disorders  in  the  activity  of 
the  myocardium  itself.  We  are  at  present,  it  is  true,  not  yet  m  a  posi- 
tion to  distinguish  definitely  one  from  the  other,  or  to  estimate  the  share 
each  takes  in  their  apparently  frequent  combinations. 


390  TYPHOID  FEVER. 

The  most  important  guide  to  the  .state  of  the  circulatoiy  organs  is 
furnished,  now  as  always,  by  a  study  of  the  pulse.  Its  frequency 
alone  may  be  of  considerable  importance — less,  it  is  true,  in  the  case  of 
women,  children,  and  other  nervous  individuals,  than  in  that  of  robust 
men  or  chlerly  persons  of  either  sex.  While  in  the  former  great  fre- 
quency of  pulse  appearing  early  is  common,  and  is  of  itself  of  little 
significance,  it  must,  in  strong  young  men  or  elderly  persons,  even  by 
itself  admonish  the  clinician  to  exercise  great  caution  in  prognosis.  It 
may  even  be  a  matter  of  concern  if  in  an  apparently  strong  man  the 
almost  typical  relative  slowness  of  the  pulse  so  generally  present  in 
the  first  half  of  the  febrile  stage  remains  absent.  Diminution  in  the 
tension  and  alteration  in  the  regidarity  of  the  pulse  are  naturally  to  be 
considered  still  more  serious  than  increased  frequency,  and  in  this  con- 
nection, as  has  been  pointed  out,  more  importance  is  to  be  attached  to 
irregularity  in  force  than  to  mere  irregularity  in  rhythm.  As  a  matter 
of  course,  these  disturbances  are  all  the  more  significant  the  earlier  they 
appear,  the  longer  they  last,  and  the  more  positively  it  can  be  stated 
that  they  are  not  dependent  upon  probably  transitory  complications. 

The  extraordinary  prognostic  importance  of  the  state  of  the  circula- 
tion was  especially  appreciated  by  earlier  physicians.  With  the  intro- 
duction of  thermometry,  and  the  primary  enthusiasm  aroused  by  this 
new  method,  it  was  undeservedly  pushed  somewhat  into  the  background. 
At  the  present  day  it  has  been  restored  to  its  proper  position,  and  there 
is  no  doul)t  that  for  individual  prognosis,  on  the  whole,  the  state  of 
the  pulse  affords  better  and  safer  guidance  than  that  of  the  body- 
temperature. 

The  prognostic  interpretation  of  the  course  of  the  temperature  is  dis- 
tinctlv  more  difficult,  and  is  dependent  upon  the  most  varied  possibilities 
and  the  most  complex  conditions.  Although  formerly  decisive  value 
was  attached  to  the  absolute  height  of  the  temperature,  without  ade- 
quate consideration  of  the  general  state,  this  is  at  the  present  day  con- 
ceded to  be  but  limited,  and  applicable  only  to  rare  conditions.  Tempera- 
tures of  40°  C.  and  above,  especially  in  adults,  if  frequently  repeated, 
or  if  a  persistently  high  temperature-level  is  reached,  may  undoubtedly 
be  considered  serious.  The  prognosis  is  under  some  circumstances  ren- 
dered  unfavorable  also  by  abnormally  low  temperatures.  The  collapse 
and  pseudocollapse  previously  mentioned  should  be  borne  in  mind,  as 
well  as  the  persistently  low  temperatures,  such  as  occur  in  senile  or  in 
previously  debilitated  youthful  individuals,  and  which  become  most 
marked  in  that  dangerous  variety  of  typhoid  fever  that  pursues  an 
afebrile,  or  even  a  subfebrile,  course. 


FATAL  TERMINATION.     PROGNOSIS.  391 

Further,  prognostic  conclusions  based  upon  the  temperature  should 
not  be  formed  after  too  sliort  a  period  of  observation  ov  without  consid- 
eration of  the  remaining  circumstances.  Indeed,  the  state  of  the  body- 
temperature  in  cases  of  typhoid  fever,  as  in  some  other  infectious 
diseases,  is  as  much  dependent  upon  individual  circumstances  as  Ls  that 
of  the  nervous  system  and  the  circulatory  organs.  Every  physician, 
and  especially  the  family  practitioner,  has  inc(»ntrovertible  evidence 
of  the  fact  that  different  individuals  exhibit  not  only  different  febrile 
reactions  to  the  same  influences,  but  also  varying  degrees  of  resistance 
to  these  influences. 

Presupposing  all  this,  it  is,  nevertheless,  useful,  especially  in  the 
first  part  of  the  disease,  to  seek  prognostic  guidance  from  the  state  of 
the  temperature.  The  height  and  the  character  of  the  curve  are,  in  this 
connection,  of  equal  importance.  As  Wunderlich  and  his  pupils  have 
pointed  out,  rapid  elevation  of  the  body-temperature  in  the  initial  stage, 
without  or  with  but  a  suggestion  of  a  step-like  ascent,  and  a  high 
temperature  speedily  reached  and  maintained  for  a  considerable  time 
without  material  morning  remissions,  are  indicative  of  a  severe  course. 
Especially  the  hyperpyretic  and  fulminant  cases  are  prone  to  begin 
with  a  rapid,  uninterrupted  elevation  of  temperature  (Fig.  25,  p.  289). 
On  the  other  hand,  it  should  not  be  forgotten  that  especially  the  abor- 
tive cases  pursuing  an  unexpectedly  rapid  and  favorable  course  at  times 
set  in  in  an  almost  identical  manner. 

While  persistent  high  temperature  with  slight  remissions  is  in  gen- 
eral to  be  considered  unfavorable,  evening  exacerbations  of  even  con- 
siderable height  permit  of  a  favorable  interpretation  if  they  are  associated 
with  marked  morning  remissions,  or  even  intermissions.  It  may  be 
stated  in  general  that  the  earlier,  the  more  marked,  and  the  longer  the 
remissions,  the  more  favorable  may  the  course  be  expected  to  be. 
Naturally,  remissions  following  a  continued  fever  of  considerable  dura- 
tion may  be  welcomed  as  an  indication  of  the  early  advent  of  the  stage 
of  steep  curves.  All  these  circumstances,  however,  it  may  here  be 
repeated,  become  more  valuable  from  the  prognostic  standpoint,  the 
more  critically  the  condition  of  the  body  in  general,  and  especially  that 
of  the  pulse,  is  kept  in  view.  If  the  pulse  maintains  a  normal  course, 
danger  need  not  be  feared,  even  in  the  presence  of  an  apparently 
unfavorable  course  of  the  temperature.  In  the  presence,  however,  of  a 
suspicious  state  of  the  pulse,  no  course  of  the  temperature,  not  even 
apparently  the  most  favorable,  is  to  be  trusted.  An  important  aid  in 
the  interpretation  of  the  pulse  and  the  temperature  may  be  provided 
by  the  state  of  the  lungs.     Suspicious  changes  in  the  former  must  be 


392  TYPHOID  FEVER. 

considered  the  more  serious  when  extensive  bronchitis  appears  early  in 
previously  healthy  individuals,  inasmuch  as  its  severity,  apart  from  its 
dependence  upon  the  intensity  of  the  toxic  effect,  is  related  especially 
to  the  impairment  of  cardiac  activity.  Still  more  distinctive  in  this 
connection,  and  sometimes  evident  even  before  the  pulse  has  acquired  a 
definitely  serious  character,  is  the  early  involvement  by  a  rapidly  pro- 
gressive bronchitis  of  preferably  the  posterior  and  lower  parts  of  the 
lungs.  The  prognosis  is  naturally  most  unfavorable  with  the  onset 
of  actual  hypostatic  congestion,  simple  or  inflammatory. 

Of  the  local  typhoid  disorders  and  the  complications  already  re- 
peatedly discussed,  only  the  most  important  will  be  considered  in  this 
place,  and  then  especially  in  regard  to  their  prognostic  importance.  We 
shall  consider  first  the  state  of  the  intestinal  canal.  The  occurrence  of 
meteorism  is,  from  the  prognostic  point  of  view,  of  inestimable  signifi- 
cance. Although  its  appearance  is,  in  general,  little  to  be  desired,  its 
presence  in  marked  degree  and  its  rapid  develoj^ment  at  the  height 
of  the  disease  in  patients  the  regulation  of  whose  diet  has  not  been 
neglected  must  be  considered  as  actually  ominous.  The  meteorism  is 
then  almost  the  direct  expression  of  the  degree  of  toxic  action  upon  the 
intestinal  nervous  system  and  the  muscular  layer.  It  should,  in  this 
connection,  be  expressly  emphasized  that  the  intensity  of  the  meteorism 
is  by  no  means  in  direct  relation  to  the  severity  of  the  diarrhea,  or  even  to 
the  severity  and  the  extent  of  the  specific  typhoid  lesions  of  the  intes- 
tine. Thus,  I  have  observed  the  usual  meteorism  of  the  large  intestine 
well  marked  in  the  absence  of  the  slightest  infiltration  of  the  follicles. 

That  the  frequency  of  the  stools  is  no  index  of  the  degree  and  the 
extent  of  the  medullary  swelling  of  Foyer's  patches  and  the  solitary 
follicles  has  been  previously  emphasized.  Nevertheless,  cases  with 
severe  diarrhea  of  early  onset  and  long  duration  are  undoubtedly  to  be 
considered,  in  general,  the  more  dangerous. 

Of  great  importance  in  the  prognosis,  and  among  the  most  frequent 
causes  of  death,  are  two  other  manifestations  on  the  part  of  the  intes- 
tines, viz.,  peritonitis  and  intestinal  hemorrhage.  Peritonitis  is,  of 
the  two,  the  less  common  but  by  far  the  more  dangerous  condition. 
In  the  nature  of  things,  it  is  in  the  overwhelming  majority  of  cases  not 
circumscribed  but  diffuse,  and  therefore  usually  fatal. 

Our  Leipsic  statistics  show  that  among  the  fatal  cases  of  typhoid  fever 
death  was  due  to  peritonitis  in  16.5  per  cent.  At  Hamburg,  where  of  61 
patients  with  peritonitis  51 — 83.6  per  cent. — died,  the  proportion  of  these  to 
the  remaining  fatal  cases  was  14  per  cent.,  and  if  all  cases  of  typhoid  fever  be 
taken  into  consideration,  it  was  found  that  1.4  per  cent,  of  them  terminated 
fatally  from  this  accident.     Although,  as  has  been  mentioned,  the  severity 


FATAL  TERMINATION.      PEOONOSIS.  393 

of  the  typhoid  intestinal  lesions  varies  in  accordance  with  temporal  and 
local  influences,  the  proportion  of  fatal  cases  from  peritonitis  to  the  remain- 
ing fatal  cases  of  typhoid  fever  will,  nevertheless,  not  usually  fall  below  8 
per  cent. 

Among  the  63  fatal  cases  of  typhoid  fever  at  the  Johns  Hopkins  Hos- 
pital, 20  (31.74  per  cent.)  were  associated  with  perforation  and  peritonitis. 
Therefore,  of  the  entire  829  cases,  2.41  per  cent,  terminated  fatally  from 
this  accident. 

Although  a  much  larger  number  of  cases  of  typhoid  fever  are  seized 

with  intestinal  hemorrhag'e  than  with  peritonitis — this  condition  is 

likely  to  occur  in  from  3  to  5  and  even  up  to  7  per  cent,  of  all  cases 

— this  circumstance  is,  however,  compensated  for  by  the  fact  that  even 

in  the  severest  epidemics  not  more  than  from  20  to  30  per  cent,  of 

such  cases  terminate  fatally ;  40  per  cent,  would  be  the  extreme  limito 

Moreover,  it  should  be  emphasized  that  at  times  the  mortality  from 

intestinal  hemorrhage  is  remarkably  low,  and,  in  general,  is  far  below 

20  per  cent.     The  variability  of  the  conditions  in   this  connection  is 

shown  by  our  Hamburg  statistics  for  two  consecutive  years  of  virtually 

the  same  epidemic.     While  in  the  year  1886    20.9  per  cent,  of  the 

cases  with  intestinal  hemorrhage  died,  the  proportion  in  1887  was  only 

11.6  per  cent.     In  spite  of  the  much  slighter  danger  from  intestinal 

hemorrhage  in  the  individual  case,  its  much  greater  frequency  puts  it, 

nevertheless,  in  the  front  rank  among  the  causes  of  death.     I  should 

estimate  its  mortality  at  about  two-thirds  of  that  of  peritonitis. 

Among  the  829  cases  of  typhoid  fever  at  the  Johns  Hopkins  Hospital, 
hemorrhage  from  the  bowels  occurred  in  50  (6.03  per  cent.).  Of  these  50 
cases,  5  (10  per  cent.)  died.  Or,  of  all  the  cases  of  typhoid  fever,  0.6  per 
cent,  terminated  fatally  from  this  complication. 

Scarcely  less  dangerous  are  the  diseases  of  the  lungs,  especially 
the  various  forms  of  pneumonia,  with  their  sequels — abscess,  gangrene, 
etc..  In  severe  epidemics  from  10  to  15  per  cent,  of  all  deaths  can  be 
attributed  to  them.  By  reason  of  the  imperfect  development  of  the 
etiologic,  and  especially  the  bacteriologic,  basis  of  the  various  forms 
of  pneumonia,  it  has  hitherto  not  been  possible  to  reach  definite  views 
with  regard  to  the  prognostic  significance  of  the  individual  varieties. 
In  regard  to  the  time  of  onset,  the  forms  of  pneumonia  that  develop 
late  appear  to  be  especially  unfavorable,  because,  under  such  circum- 
stances, hypostasis,  antecedent  extensive  bronchitis,  cardiac  enfeeblement, 
and  vasomotor  disturbances  exert  an  unfavorable  influence ;  but  also 
those  cases  that  develop  at  an  earlier  period,  particularly  the  initial  cases 
progressing  under  the  picture  of  the  so-called  "  pneumotyphoid,"  may 
become  quite  dangerous.  That  age  plays  an  important  rdle  in  the  prog- 
nosis of  typhoid  pneumonia  scarcely  requires  special  mention.     While 


394  TYPHOID  FEVER. 

in  typhoid  patients  over  forty  or  forty-five  years  of  age  the  occurrence 
of  pneumonia  is  probably  always  a  fatal  complication,  the  mortality 
from  pneumonia  in  childhood  is  low.  The  favorable  condition  of  the 
heart  obviously  increases  the  powers  of  resistance  under  these  circum- 
stances. 

Pleurisy,  which  is  much  less  common,  is,  apart  from  the  presence 
of  purulent  and  putrid  eli'usions,  by  no  means  so  unfavoral)le  as  ])neu- 
monia  from  the  prognostic  standpoint.  Small  and  even  considerable 
effusions  subside  without  untoward  consequences,  even  without  the 
necessity  for  puncture.  That  patients  suffering  from  chronic  bronchitis, 
emphysema,  or  pulmonary  tuberculosis  before  the  onset  of  the  typhoid 
fever  are  exposed  to  considerable  danger  is  a  matter  of  course.  The 
relation  of  tuberculosis  to  the  course  of  the  attack  of  typhoid  fever  has 
been  fully  considered  previously. 

The  condition  of  the  kidney  is  also  of  great  importance  from  the 
prognostic  standpoint.  Even  the  cases  wdth  simple  febrile  albuminuria 
are  to  be  considered  cautiously.  This  condition  is  indicative  at  least  of 
feeble  powers  of  resistance  on  the  part  of  the  body  to  the  action  of  the 
toxins,  and  it  is,  in  general,  to  be  considered  the  graver  the  earlier  it 
appears.  The  discovery  of  the  excretion  of  albumin  may  be  of  especial 
significance  in  prognosis  if  it  occurs  at  a  time  when  the  temperature  is 
not  particularly  high,  and  when,  also,  the  pulse  exhibits  no  serious 
manifestations.  Kephritis  has  a  noteworthy  influence  upon  the  mor- 
talitv,  although  it  is  not  so  important  in  this  connection  as  the  diseases 
of  the  intestines  and  the  lungs.  Although  with  regard  to  the  frequency 
of  its  occurrence  it  occupies  a  position  far  behind  the  latter,  it  causes, 
on  the  other  hand,  a  fatal  issue  in  half  of  those  attacked. 

The  unfavorable  prognosis  of  so-called  nephrotyphoid  is  gen- 
erally recognized,  but  it  is  by  some  French  investigators,  however, 
exaggerated  far  beyond  the  actual  degree.  Of  605  fatal  cases  in  Ham- 
burg and  Leipsic,  27 — 4.5  per  cent. — were  attributable  to  complicating 
nephritis.  The  uniformity  of  its  occurrence  in  both  sets  of  statistics  is 
noteworthy  :  while  of  243  fiital  cases  at  Leipsic,  death  was  due  in  11 — 
4.6  per  cent. — ^to  nephritis,  among  the  362  at  Hamburg,  nephritis  was 
the  immediate  cause  of  death  in  16 — 4.4  per  cent.  A  ray  of  light  in 
the  gloomy  prognosis  of  nephritis  may  be  found  in  the  fact  that  if  it 
does  not  cause  death,  complete  recovery  generally  follows.  I/Ong- 
continued  albuminuria  or  transition  into  chronic  nephritis  is  less 
common  in  connectif>n  wath  typhoid  fever  than  with  some  other  infec- 
tious diseases. 

Although  it  has  been  necessary  to  emphasize  the  influence  of  the 


FATAL   TERMINATION.      PROGNOSIS. 


395 


toxin  upon  the  heart  and  the  vasomotors  in  general,  the  individual 
diseases  of  the  myocardium,  the  pericardium,  and  the  endocardium  as 
causes  of  death  are  inconsiderable.  The  prognosis  of  typhoid  n)y(jcar- 
ditis  has  already  been  pointed  (^ut  as  not  so  uniavorabl(;  as  it  might 
appear  from  the  influence  of  the  same  condition  in  other  infectious 
diseases,  as,  for  instance,  in  diphtheria.  Some  significance  is,  never- 
theless, to  be  attached  to  tyjDhoid  myocarditis  in  the  explanation  of 
cases  of  sudden  death. 

It  is  not  worth  while  to  discuss  individually  the  remaining  organs  and 
systems  with  regard  to  their  influence  upon  the  mortality  and  the  prognosis. 
They  are  rare  or  only  occasional  occurrences,  and  do  not  require  special 
comment.  The  best  idea  of  the  conditions  present  in  this  connection  will 
be  afforded  by  the  following  tabular  arrangement  of  the  principal  causes 
of  death  in  580  cases  observed  at  Hamburg  and  Leipsic : 


Causes  of  Death. 


Severity  of  the  infection        .        .    . 

Intestinal  perforation,  peritonitis     . 

Intestinal  hemorrhage 

Pneumonia 

Nephritis 

Hemorrhagic  diathesis 

Pyemia,  septicemia 

Erysipelas 

Decubitus 

Multiple  abscesses 

Noma 

Ulcerative  laryngitis,  necrosis  of 
cartilage,  and  sequels 

Pulmonary  edema 

Serofibrinous  exudative  pleurisy  .    . 

Empyema  of  the  pleura 

Pyopneumothorax 

Pulmonary  tuberculosis  and  mili- 
ary tuberculosis 

Pulmonary  embolism 

Fatty  heart  (myocarditis  ?)   .    ,    .    . 

Endocarditis      

Delirium  tremens 

Meningeal  hemorrhage 

Purulent  meningitis  with  caries  of 
the  temporal  bone 

Diphtheria 

Abortion  and  premature  labor  .    .    . 

Pyosalpinx,  perforative  peritonitis  . 


Total 


Hamburg. 


Number  of 
cases. 


186 
51 
24 
56 
16 

'  2 
4 


Percentage. 


51.4 
14.1 

6.6 
15.5 

4.3 

0.5 
1.1 


0.3 


Leipsic. 


'c^set^"     I  Percentage. 


40 

19 

24 

11 

5 


1.1 

1 

0.8 

0.8 

0.8 

0.3 

0.8 

3 

0.3 

2 

0.5 

1 

0.3 

1 

0.8 

0.3 

0.3 

0.3 

1 

4 

1 

367 


213 


42.4 
19.0 
9.0 
11.4 
6.2 
2.3 
3.8 

0.9 
0.5 


0.4 


1.4 
0.9 
0.4 
0.4 


0.4 
1.9 
0.4 


With  regard  to  the  manner  in  which  death  occurs,  it  is 

scarcely  worth  speaking  in  detail.  From  what  has  been  previously 
said,  it  will  appear  that  it  is  most  frequently  preceded  by  symptoms 
of  the  most  profound  intoxication,  Avith  paralysis  of  the  heart  and  the 
nervous  system,  and  these  are  not  much  difi'erent  in  cases  of  typhoid 


396  TYPHOID  FEVER. 

fever  than  iu  other  acute  infectious  diseases.  At  later  periods  of  the 
disease  the  fatal  termination  is  generally  attended  with  symptoms  of 
exhaustion  and  of  marasmus,  or  those  of  complications.  Eacli  of  the 
fatal  local  disorders  naturally  impresses  with  its  particular  stamp  the 
manner  in  which  death  occurs. 

SUDDEN  DEATH. 

In  concluding  this  chapter,  only  the  cases  of  sudden  death  in  the 
course  of  typhoid  fever  will  be  considered  somewhat  more  in  detail. 
These  include  the  cases  that  remain  indelibly  fixed  in  the  memory  of 
the  physician,  in  which,  quite  unexpectedly,  during  convalescence  of 
apparently  satisfactory  progress,  there  occur  suddenly,  like  a  lightning- 
stroke  or  after  a  short  inters^al,  the  alarming  symptoms  to  which  the 
patient  succumbs. 

As  with  so  many  striking  clinical  features  which  are  especially 
impressed  upon  the  memory  of  the  physician,  and  are  therefore  more 
frequently  described  and  mentioned  in  statistics,  so,  with  regard  to  the 
cases  of  sudden  death,  an  impression  has  unconsciously  been  gained  that 
they  are  far  more  frequent  than  they  really  are.  On  the  contrary,  I 
consider  their  occurrence  as  actually  infrequent,  and  believe,  in  addi- 
tion, that  it  can  often  be  prevented  if  in  the  later  stages  of  the  disease, 
particularly  the  period  of  convalescence,  the  patients  are  carefully 
watched,  and  are  kept  at  rest  physically  and  mentally,  and  are  not 
permitted  to  get  out  of  bed  too  soon.  This  statement  implies  that  the 
cases  of  sudden  death  are  likely  to  occur  especially  in  the  period  of 
defervescence,  and  even  still  more  frequently  in  that  of  convalescence. 
The  unfortunate  occurrence  is  incomparably  less  common  at  the  height 
of  the  disease,  and  it  has  been  observed  only  exceptionally  in.  the  first 
week. 

It  w^ould  be  a  mistake  to  believe  that  cases  of  sudden  death  occur 
wath  preference  in  persons  who  already  are  especially  debilitated  by  rea- 
son of  constitution,  age,  previous  disease,  severe,  protracted  coarse  of  the 
attack,  or  complication.  On  the  contrary,  robust  youthful  individuals 
are  attacked  quite  as  often,  almost  still  more  frequently,  even  after 
attacks  of  the  disease  of  moderately  severe  or  even  mild  course.  This 
indicates  that  in  this  connection  antecedent  predisposition  or  the  severity 
of  the  disease  itself  is  of  less  influence  than  certain  more  or  less  unantici- 
pated alterations  that  appear  in  the  course  or  after  the  termination  of 
the  disease. 

Most  frequently  the  cases  of  sudden  death  occur  under  the  following 
conditions  :     The  patient,  apparently  previously  well,  but  still  languid 


FATAL  TERMINATION.      PROGNOSIS.  397 

and  weak,  or  with  complaint  of  transient  palpitation  of  the  heart, 
exhibiting  a  rather  small,  unstable,  and  freqncnt  ])ulse,  suddenly,  in  or 
out  of  bed,  generally  while  engaged  in  some  ])hysical  effort^ — sitting  up 
to  take  food,  or  for  examination  or  defecation,  or  indulging  in  short 
walks  contrary  to  the  instructions  of  the  physician — becomes  pale  and 
collapses,  falls  back,  and  dies  within  a  few  minutes.  If  the  physician 
soon  reaches  the  patient,  he  will  generally  still  be  able  to  notice  some- 
what stertorous  breathing,  while  the  pulse  is  already  imperceptible  and 
the  heart-sounds  are  scarcely  audible.  The  impression  is  gained  that 
the  patient  has  succumbed  to  actual  heart-failure,  to  which  cerebral 
anemia,  as  one  of  the  manifestations  of  j)rofound  blood-change,  has  con- 
tributed its  share.  To  this  the  layman  gives  expression  by  attributing 
death  to  cardiac  failure. 

The  occurrence  of  sudden  death  in  cases  of  typhoid  fever  has  for  a 
long  time  been  emphasized  in  the  literature  (Chomel,  Louis,^  Murchi- 
son  ^).  The  condition  has  been  more  thoroughly  studied  recently  by 
Hayem,^  Bussard,*  and  Huchard^;  in  Germany,  soon  afterward,  by 
Leyden  *  and  his  pupil,  Hiller,''  in  an  especially  noteworthy  communica- 
tion. The  question  was  further  elucidated  by  the  investigations  of 
Romberg  *  upon  typhoid  myocarditis  in  my  clinic.  These  more  recent 
publications  have  shown  that  inflammatory  alterations  of  the  myocar- 
dium play  the  most  important  role  in  this  connection,  while  the  earlier 
investigators  assumed  only  fatty  degeneration  with  atony,  dilatation, 
and  friability  of  the  myocardium. 

Among  the  French  writers  certain  differences  have  arisen  recently 
in  that  some  believe  that  sudden  death  occurs  especially  or  exclusively 
from  cardiac  failure,  while  Huchard,  Bussard,  and  in  part  also  Dieulafoy,* 
consider  cerebral  anemia  as  the  more  important  cause.  I  believe  that 
we  have  to  do  here  with  an  unpromising  controversy,  and  that  both 
factors  are  inseparably  necessary  for  a  full  explanation  of  the  cases  in 
question.  I  have  personally,  when  I  have  been  able  to  watch  my 
patients  carefully,  particularly  in  the  hospital,  observed  only  a  few  cases 

'  Loc.  cit. 

2  Jour,  of  Med.  Sci.,  March,  1867,  cited  by  Hiller.  It  is  interesting  and  indica- 
tive of  the  rarity  of  the  event  that  Murchison,  with  his  acute  powers  of  observation, 
does  not  even  mention  the  cases  of  sudden  death  in  his  well-known  book. 

^  Loc.  cit.  *  Cited  by  Virchow-Hirsch,  Jahresbericht,  1876,  Bd.  ii. 

*  Union  med.,  1877. 

^  In  his  publication  upon  the  cardiac  affections  of  diphtheria,  Zeit.  f.  klin.  Med.y 
1883,  Bd.  iv. 

'  Charite-Annalen,  1883.  This  paper  contains  also  additional  bibliographic  refer- 
ences and  statistical  data.  ^  Loc.  cit. 

9  Gaz.  hebd.,  1877,  Nos.  20  and  22. 


398  TYPHOID  FEVER. 

of  sudden  death,  undoubtedly  because  I  permit  my  convalescents  to  get 
up  comparatively  late,  aud  exercise  particular  care  with  auemic  patients 
who  present  suspicious  activity  of  the  heart. 

Of  my  few  cases,  two  may  be  described  briefly  here :  A  healthy,  vit^for- 
ous  merchant,  tweuty-two  years  old,  after  haviug  served  in  the  army  the  lirst 
nine  mouths  of  his  term  of  a  year,  was  attacked  during  the  last  period  of  his 
service.  He  continued  to  drag  himself  about  for  the  first  week,  but  during 
the  following  week  was  nursed  in  the  lazaretto,  aud  subsequently  at  home. 
In  the  fourth  week  he  was  free  from  fever,  had  a  good  appetite,  and  was  in  a 
contented  frame  of  mind,  so  that  the  patient  and  his  friends  considered  it 
pedantic  that  I  forbade  his  getting  up  after  twelve  afebrile  days  had  passed. 
^ly  prohibition  was  based  upon  the  fact  that  the  patient,  in  spite  of  sub- 
normal temperature,  still  continued  to  exhibit  a  soft,  uow  aud  again  inter- 
mittent, pulse  of  more  than  80,  and  at  the  same  time,  with  clear  but  faint 
heart-sounds,  exhibited  the  signs  of  slight  dilatation  of  the  myocardium. 
Ou  the  fourteenth  day  of  convalescence  the  nurse,  retained  by  my  direction, 
on  returning  to  the  room  after  an  absence  of  scarcely  ten  minutes,  found  the 
patient  lying  in  front  of  the  bed,  unconscious  and  pulseless  ;  and  before  she 
was  able  to  summon  assistance  the  patient  was  dead.  Apparently,  the  patient 
had,  contrary  to  instructions,  got  out  of  bed  for  the  purpose  of  urinating. 
Post-mortem  examination  was  not  permitted. 

The  second  case  is  especially  noteworthy,  because  I  was  present  when 
death  occurred.  The  patient  was  a  woman,  thirty-one  years  old,  who,  after 
a  moderately  severe  attack  of  typhoid  fever  of  four  weeks'  duration,  without 
complications,  had  been  free  from  fever  for  five  days.  The  pulse  ranged 
from  90  to  100  in  the  morning,  up  to  112  in  the  evening,  was  moderately 
full,  tense,  and  regular,  but  still  quite  variable  in  frequency,  so  that  during 
speaking  or  on  slight  movements  after  eating,  at  times  also  without  extra- 
neous cause,  the  frequency  was  increased  from  10  to  30  beats  a  minute. 
The  area  of  cardiac  dulness  was  apparently  normal  ;  the  sounds  were  dull 
and  faint;  no  murmur  was  audible.  I  had  examined  the  patient  at  the 
morning  visit  and  had  found  nothing  wrong,  and  at  her  request  had  even 
enlarged  the  diet.  After  I  had  got  a  distance  of  three  beds  away  I  was 
recalled.  The  patient  had  sat  up  and  had  reached  for  a  letter  which  had 
been  received  the  evening  before,  and  which  we  subsequently  found  to  be 
of  an  exciting  character,  had  suddenly  become  pale,  and  had  fallen  back  upon 
the  pillow  unconscious.  Scarcely  a  minute  elapsed  before  I  saw  the  patient 
again,  but  her  features  were  already  relaxed,  the  pupils  were  dilated  and 
fixed,  the  pulse  was  no  longer  perceptible,  and,  after  a  few  stertorous  breaths, 
death  had  taken  place  without  complaint  or  sound.  Post-mortem  examina- 
tion disclosed  numerous  recent  cicatrices  in  the  lower  portion  of  the  ileum 
and  the  adjacent  portion  of  the  large  intestine.  The  brain  and  the  lungs 
exhibited  no  peculiarities.  The  heart  was  moderately  dilated  and  relaxed. 
The  myocardium  was  yellowish  gray  in  color,  friable,  and  brittle.  Micro- 
scopic examination  disclosed  fatty  degeneration  and  segmentation  of  the  mus- 
cular fibres,  with  partial  obliteration  of  the  transverse  striation.  The  case 
was  observed  at  a  time  when  thorough  microscopic  investigation  of  typhoid 
myocarditis  was  not  made,  but  I  have  no  doubt  that  the  condition  was  of 
this  character. 

In  addition  to  myocarditic  paralysis  of  the  heart  and  cerebral  anemia 
as  a  cause  of  sudden  death,  pulmonary  embolism  undoubtedly  also  plays 


FATAL   TERMINATION.      PROGNOSIS.  399 

an  important  role.  The  emboli  are  derived  in  part  from  the  cerebral 
sinuses  (Griessinger)  and  the  peripheral  veins,  ])articnlarly  those  of  tlie 
extremities,  and  partly  from  the  right  side  of  the  heart.  Marvaud  ' 
undoubtedly  goes  too  far  in  attributing  the  majority  of  all  cases  of  sud- 
den death  to  cardiac  thrombosis.  The  reports  of  his  own  autopsies 
show  that  in  addition  to  thrombosis  there  was  present  profound  degene- 
ration of  the  myocardium. 

Much  less  common  than  pulmonary  embolism  as  a  cause  of  sudden 
death  is  embolism  of  the  cerebral  arteries.  I  have  previously  men- 
tioned a  case  of  my  own  (basilar  artery).  Hemorrhage  iDt<>  the  sub- 
stance of  the  brain  and  the  meninges  is  not  more  common.  It  occurs  in 
cases  of  the  hemorrhagic  variety,  as  well  as  now  and  then  in  alcoholic 
patients. 

The  view  maintained  by  a  few  French  investigators,  that  death  may 
result  in  consequence  of  sudden  peculiar  intensification  of  the  typhoid 
intoxication,  is  for  the  present  without  firm  support.  Nothing,  also,  of 
a  definite  character  has  as  yet  been  demonstrated  for  other  toxic  condi- 
tions, as,  for  instance,  uremia  causing  apoplexy.  The  view  of  Dieulafoy,^ 
that  death  may  be  caused  by  reflex  spasm  in  the  structures  innervated 
from  the  medulla  oblongata,  particularly  by  the  pneumogastric  nerve, 
excited  by  the  diseased  intestine,  is  based  essentially  upon  the  fact  that 
in  the  clinical  observations  upon  which  this  view  is  based  local  altera- 
tions of  an  explanatory  character  were  not  found.  The  theory  has,  so 
far  as  I  know,  remained  without  supporters,  and  has  been  restricted 
and  altered  by  its  promulgator  in  a  later  communication.^ 

■  Arch.  gen.  de  med.,  Aug.  and  Sept.,  1880. 

2  These,  Paris,  1869 ;  Virchow's  Jahresbericht,  1869,  Bd.  ii.  ^  Loc.  cit. 


III.  DIAGNOSIS. 

The  ideal  method  of  diagnosis  of  typhoid  fever  would  be  the  dem- 
onstration with  readiness,  rapidity,  and  certjiiuty  of  its  cause,  the  bacil- 
lus of  Ebeilh,  during  eveiy  period  of  the  disease.  Unfortunately,  this 
most  natural  method  is  not  yet  available  in  a  degree  at  all  approaching 
perfection.  Questions  have  at  times  even  been  raised  as  to  the  possi- 
bility of  distinguishing  the  typhoid-bacillus  from  other  organisms  (colon- 
bacillus  group)  resembling  it  morphologically  and  biologically.  But 
to-day  we  know  that  it  has  definite  and  peculiar  characteristics  which 
distinguish  it  from  all  other  organisms.  Foremost  among  these  special 
featui'es  is  its  specific  reaction  to  the  blood  and  the  body -fluids  of  typhoid 
patients  and  immune  animals.  These  present  methods  of  distinguishing 
this  organism,  however,  while  relatively  simple  for  the  experienced  bac- 
teriologist, present  considerable  difficulties  for  the  practitioner.  But 
aside  from  the  identification,  it  is  not  an  entirely  easy  task  to  isolate  the 
organism  directly  from  the  patient  or  his  secretions.  The  methods  are 
constantly  being  simplified,  however,  and,  where  means  are  available, 
cultures  from  the  urine,  feces,  rose-spots,  and  especially  the  blood,  are 
frequently  of  the  greatest  aid  in  diagnosis.  Later  work  with  newer 
methods  has  shown  the  presence  of  typhoid-bacilli  in  the  circulating 
blood  in  70  to  80  per  cent,  of  the  cases,  frequently  quite  early  in  the 
disease ;  and  it  is  to  be  hoped  that  further  improvements  in  methods 
may  make  the  demonstration  of  its  constant  presence  possible,  and  make 
the  method  readily  available  for  clinical  purposes. 

The  method  of  serum-diagnosis  made  possible  by  the  labors  of 
Pfeiffer,  Gruber,  and  Widal  has  been  shown  by  a  large  number  of 
reports  and  by  its  almost  universal  use  at  present  to  be  of  great  aid 
in  diagnosis,  even  though,  on  account  of  the  very  frequently  delayed 
appearance  of  the  reaction,  it  has  not  proved  to  be  of  quite  so  much 
diagnostic  value  as  was  at  first  hoped. 

But  however  valuable  these  methods  of  bacteriologic  diagnosis  may 
be  in  certain  cases,  it  must  be  emphasized  that  at  present  observation 
at  the  bedside  still  retains  the  first  place  in  diagnosis.  It  would  be  a 
serious  blow  to  the  further  development  of  our  clinical  knowledge  if 
the  former  methods  should  displace  ctireful  general  and  visceral  exami- 
nation.    But  just  as  little  as  exploratory  puncture  or  even  exploratory 

400 


DIAGNOSIS.  401 

celiotomy  is  likely  to  restrict  thorough  clinical  investigation,  so  little 
also  is  it  probable  that  the  bacteriologic  method  will  ever  be  the  exclu- 
sive one  in  the  diagnosis  of  infectious  diseases. 

There  are,  however,  certain  cases  in  which  the  most  skilful  and 
painstaking  clinical  study  alone  cannot  make  a  certain  diagnosis,  but 
which  may  often  be  definitely  decided  by  bacteriologic  methods.  The 
routine  use  of  laboratory  methods  whenever  possible  cannot,  therefore, 
be  too  strongly  urged  if  an  accurate  and  certain  diagnosis  is  to  be  made 
in  all  cases.  They  do  not  and  cannot  take  the  place  of  careful  clinical 
observation,  but  must  be  regarded  simply  as  aids  and  accessory  factors 
in  arriving  at  diagnostic  conclusions. 

CLINICAL  INVESTIGATION. 

In  accordance  with  the  foregoing  point  of  view  we  place  clinical 
investigation  in  advance  of  the  bacteriologic  methods.  Although  we 
have  no  knowledge  as  yet  of  any  clinical  sign  of  typhoid  fever,  which 
is  in  itself  conclusive  from  the  diagnostic  standpoint,  there  are,  never- 
theless, a  number  of  symptoms  that,  grouped  in  accordance  with  the 
manner  and  time  of  their  appearance,  their  sequence,  and  their  asso- 
ciation, may  admit  of  almost  complete  diagnostic  certainty. 

The  diagnosis  of  typhoid  fever  is  by  no  means  difficult  if  a  case 
pursuing  a  typical  course  can  be  observed  at  the  outset  and  for  a  consid- 
erable time ;  and  if,  in  addition,  one  is  informed  with  regard  to  the 
remote  and  the  immediate  circumstances  attending  its  development. 
The  situation  becomes  far  more  difficult,  however,  if,  in  the  absence  of 
knowledge  of  the  antecedent  conditions,  a  decision  must  be  reached  at 
once  or  after  a  short  period  of  observation,  and  if  the  case  is  seen  only 
at  a  later  stage  or  if  the  attack  is  an  abbreviated  one  or  one  pursuing  a 
wholly  atypical  course. 

It  is  particularly  noteworthy  and  always  to  be  kept  in  mind  that 
the  so-called  typhoid  state — that  symptom-complex  that  formerly  occu- 
pied the  most  prominent  position  with  regard  to  the  recognition  of  the 
disease — has  lost  more  and  more  of  its  diagnostic  significance,  and  that 
at  the  present  day  it  is  recognized  to  have  been  an  obstacle  to  diagnostic 
progress  in  the  past.  At  the  present  day  it  can  only  be  said  that  an  indi- 
vidual presenting  the  typhoid  state  has  been  for  some  time  and  in  severe 
degree  exposed  to  the  influence  (of  the  toxins)  of  an  acute  infectious 
disease ;  whether,  however,  this  is  typhoid  fever  or  some  acute  disease, 
as,  for  instance,  typhus  fever,  septicemia,  meningitis,  or  mihary  tuber- 
culosis, is  a  question  for  further  careful  consideration. 

The  most  important  features,  especially  with  regard  to  typhoid  fever, 

26 


402  TYPHOID  FEVER. 

to  be  taken  into  consideration  in  this  connection  are  the  character  of 
the  febrile  course,  particularly  the  character  of  the  temperature-  and 
pulse-curves  and  their  relations  to  each  other,  the  acute  enlargement  of 
the  spleen,  the  appearance  of  a  peculiar  roseolous  eruption,  and  the 
character  of  tlie  stools.  Next  in  importance  are  bronchitis  and  pul- 
monary hypostasis,  the  state  of  the  blood,  especially  of  the  leukocytes, 
and  the  demonstration  of  the  diazo-reaction. 

With  regard  to  the  course  of  the  temperature,  the  character 
of  its  ascent,  in  the  well-known  step-like  manner,  as  a  result  of  which 
the  height  of  the  fever  and  the  beginning  of  the  fastigium  are  reached 
in  the  course  of  three  or  four,  at  most  five,  days,  may  be  of  great  weight 
in  the  diiferential  diagnosis.  Scarcely  any  other  infectious  disease  to  be 
taken  into  consideration  exhibits  this  mode  of  onset.  It  is  true  that  the 
contrary  condition — rapid,  miiuterrupted  elevation  of  the  temperature — 
does  not,  as  has  already  been  seen,  exclude  typhoid  fever,  although  it  is 
far  more  frequently  observed  in  connection  with  other  infectious  dis- 
eases or  with  incomplete  abbreviated  cases  of  tyjjhoid  fever.  If  one 
hears  Wimderlich's  rules  declared  schematic  by  members  of  the  younger 
generation,  they  should  be  made  to  understand  that  he  was  less  familiar 
with  the  afebrile  and  the  incomplete  varieties  of  the  disease,  with  regard 
to  then'  course  and  frequency,  than  we  are  at  the  present  day,  and  that 
he  was  correct,  now  as  then,  if  his  conclusions  are  applied  to  the 
moderate  and  the  severe  complete  cases. 

That  the  fastigium,  with  its  peculiar  temperature-course  of  con- 
tinued fever  or  remittent  continued  fever,  and  particularly  its  duration, 
may  be  decisive  in  diagnosis  need  be  but  again  mentioned  at  this  point,  as 
this  subject  has  been  discussed  in  previous  chapters.  The  mode  of  defer- 
vescence, in  the  form  of  the  characteristic  steep  curves,  may  also  here  be 
referred  to.  In  addition,  it  should  be  pointed  out  that  when  the  disease 
pursues  a  mild  course  and  at  a  certain  age,  especially  in  childhood, 
very  early  remissions  and  intermissions  in  the  temperature-curve  should 
arouse  suspicion  of  typhoid  fever ;  however,  this  is  true  also  of  several 
other  diseases  which  in  other  respects  enter  into  consideration  in  the 
differential  diagnosis.  The  subnormal  temperatiu'e,  which  almost  con- 
stantly and  for  a  considerable  time  f()llow\s  defervescence,  is  also  to  be 
borne  in  mind  in  this  connection.  Although  in  itself  it  indicates  only 
recovery  from  a  severe  debilitating  infectious  disease,  in  no  other  disease 
does  it  appear  so  constantly  and  is  so  persistent  as  in  cases  of  typhoid 
fever.  That  the  temperature-curve  may  be  irregular,  variable,  and 
wholly  uncharacteristic  in  the  various  incom])lete  forms  of  the  disease 
has  likewise  been  fully  pointed  out  previously. 


DIAGNOSIS.  403 

The  character  of  the  pulse  is  noteworthy  on  account  of  its  slow- 
ness, especially  in  youthful,  vigorous  males.  Its  remarkable  slowness 
in  comparison  to  the  height  of  the  temperature  does  not  occur  anywhere 
nearly  so  often  in  any  other  disease  to  be  taken  into  consideration  from 
the  standpoint  of  differential  diagnosis.  Even  the  slowing  of  the  puLse 
attending  basilar  meningitis  is  readily  to  be  distinguished  from  that 
of  typhoid  fever  by  the  time  and  the  mode  of  its  appearance. 

The  dicrotism  of  the  pulse  is  also  of  diagnostic  significance. 
It  is  much  more  common  in  cases  of  typhoid  fever  than  in  all  the  other 
infectious  diseases  taken  together ;  it  occurs  in  typhoid  fever  especially 
in  persons  in  the  bloom  of  youth,  in  later  childhood,  and  even  in  older 
individuals  who  have  not  too  marked  changes  in  the  walls  of  the 
arteries.  If  both  phenomena,  slowing  and  dicrotism,  are  observed 
together,  this  fact  may  materially  strengthen  the  diagnosis,  even  in 
differentiation  from  basilar  meningitis,  in  which,  in  addition  to  slowing, 
dicrotism  is  scarcely  ever  observed. 

The  state  of  the  spleen  is  of  diagnostic  value  if  its  acute 
enlargement  is  observed  to  occur  toward  the  end  of  the  first  or  at  the 
beginning  of  the  second  week,  after  the  step-like  ascent  of  the  tempera- 
ture-curve has  taken  place.  In  no  other  acute  infectious  disease  is  the 
occurrence  of  enlargement  of  the  spleen,  especially  at  the  time  stated, 
even  approximately  so  frequent ;  and  in  none  does  this  condition  persist 
so  long — into  the  third  or  the  fourth  week  of  the  disease,  and  perhaps 
longer.  It  is  comparatively  rare  for  the  enlargement  of  the  spleen  to 
appear  before  the  beginning  of  the  fever  or  during  the  very  first  days 
of  the  disease,  and  this  distinguishes  typhoid  fever  from  typhus  fever, 
and  from  the  acute  exanthemata,  to  which  typhus  is  closely  related,  if 
these  diseases  should  ever  be  attended  with  any  enlargement  of  the 
spleen.  The  state  of  the  spleen  during  relapses  is  also  noteworthy. 
The  persistence  or  the  reappearance  of  its  enlargement  after  the  primary- 
defervescence  of  the  fever  is  indicative  of  an  impending  relapse,  and  aids 
in  distinguishing  it,  if  it  develop,  from  febrile  conditions  of  other  origin. 

Although  the  typhoid  stools  possess  no  quality  that  is  peculiar  to 
them,  nevertheless  their  color,  their  watery  character,  with  the  result- 
ing tendency  to  the  formation  of  layers,  the  yellowish,  disintegrating 
sediment,  the  crystals,  the  penetrating  odor,  together  with  the  relative 
infrequency  of  the  discharges,  are  often  quite  distinctive.  It  is  true 
that  the  diarrhea  is  less  constant  than  the  enlargement  of  the  spleen. 
It  has  already  been  seen  that  scarcely  one-third  of  all  cases  exhibit  thin 
stools  for  a  considerable  time,  while  not  a  few,  on  the  contrary,  are 
even  attended  with  persistent  constipation. 


404  TYPHOID  FEVER 

Diagnostic  significance  is  to  be  attached  also  to  the  occurrence  of 
meteorism,  which  likewise  is  by  no  means  so  frequent  as  some 
believe.  It  is  true  that  it  is  scarcely  dependent  directly  upon,  or 
stands  in  any  other  relation  to,  the  ulcerated  state  of  the  bowel ;  but,  on 
the  other  hand,  it  is,  as  has  already  been  pointed  out,  merely  a  result 
of  the  intluence  of  the  toxin  upon  the  intestinal  wall.  As  it  may 
develop  in  a  similar  manner,  although  less  commonly,  in  the  course  of 
other  acute  infectious  diseases,  especially  pyemic  processes  and  general 
miliary  tuberculosis,  it  may  at  times  even  increase  the  difficulty  of 
diagnosis. 

The  most  significant,  almost  specific,  manifestation  is  the  roseolous 
exanthem.  Only  with  extreme  rarity  and  only  in  a  few  other  dis- 
eases do  eruptions  occur  that  can  scarcely  be  distinguished  from  the 
typhoid  roseolse  even  by  an  expert.  Personally,  this  has  occurred  to 
me  exceptionally  in  cases  of  acute  miliary  tuberculosis,  and  it  is  reported 
also  by  reliable  writers  with  regard  to  cerebrospinal  meningitis  and 
trichinosis.  In  addition,  the  roseolous  eruption  is  among  the  principal 
signs  of  typhoid  fever,  almost  the  most  frequent — by  far  more  constant 
than  the  altered  state  of  the  bowels,  perhaps  even  than  of  the  enlarge- 
ment of  the  spleen,  and  at  any  rate  is  in  general  more  readily  and  more 
certainly  recognizable  than  the  latter.  If,  in  addition,  the  time  of  the 
first  appearance  and  that  of  the  disappearance  of  the  roseolae,  their 
appearance  in  crops,  their  characteristic  distribution  upon  the  body,  and 
the  short  duration  of  the  individual  efflorescence  be  taken  into  consid- 
eration, they  may  be  considered  as  one  of  the  most  valuable  signs  of 
typhoid  fever,  and  all  the  more  so  as  their  occurrence  and  the  degree  of 
their  development  are  not  proportionate  to  the  severity  or  the  mildness 
of  the  cases ;  so  that,  especially  in  the  atypical  cases  difficult  of  diag- 
nosis, a  distinctive  criterion  is  at  times  thus  affijrded. 

Crystalline  miliaria,  although  one  of  the  most  frequent  cuta- 
neous lesions  of  typhoid  fever,  is  far  less  significant  from  the  diagnostic 
standpoint  than  the  roseolse.  The  circumstance  that  it  appears  relatively 
much  later  than  the  latter,  and  with  distinctly  greater  frequency  in 
severe  and  otherwise  typical  cases,  explains  this  fact.  In  addition,  it 
occurs  by  far  much  more  frequently  in  other  diseases.  I  have  observed 
it  rather  commonly,  especially  in  acute  septic  states,  typhus  fever,  and 
miliary  tuberculosis. 

The  negative  role  taken  by  herpetic  eruptions  is  worthy  of 
mention  at  this  place.  Almost  all  experienced  writers  are  in  agreement 
that  facial  herpes  occurs  so  rarely  in  typhoid  fever,  even  in  the  first 
febrile  period,  that  its  appearance  in  the  initial  stage  of  an  infectious 


DIAGNOSIS.  405 

disease  of  doubtful  character  is  against  its  being  typhoid.  Especially 
certain  diseases  that  are  often  to  be  most  carefully  considered  in  the 
differential  diagnosis  of  typhoid  fever  in  the  initial  stage — viz.,  pneu- 
monia, cerebrospinal  meningitis,  typhus  fever,  malaria,  and  others — 
are,  however,  characterized  by  the  frequency  with  which  herpes  occurs. 

The  diagnostic  significance  of  typhoid  bronchitis  is  not  incon- 
siderable, and  upon  this  I  place  emphasis,  in  contradistinction  to 
other  writers.  Although  it  presents  nothing  characteristic  as  an  indi- 
vidual symptom  and  attends  all  other  possible  infectious  diseases,  and 
some  even  in  special  degree,  it  may  be  a  valuable  sign  in  the  not 
infrequent  cases  in  which,  although  the  existence  of  a  febrile  disease 
has  been  determined,  other  symptoms  distinctive  either  of  typhoid  fever 
or  of  some  other  infectious  disease  have  not  yet  been  recognized.  The 
occurrence  of  diffuse  bronchitis  at  the  end  of  the  first  or  the  beginning 
of  the  second  week,  in  spite  of  the  absence  of  other  pronounced  symp- 
toms, indicates  the  presence  of  a  severe  infectious  process ;  and  under 
such  circumstances  the  probability  that  it  is  typhoid  fever  is  most 
likely. 

Among  the  symptoms  that  have  recently  been  recognized  to  possess 
diagnostic  significance  the  diaizjO -reaction  may  next  be  considered. 
It  has  been  seen  that  it  occurs  almost  always  in  cases  of  typhoid  fever 
in  children,  and  in  adults  also  in  the  vast  majority  of  cases,  and  gener- 
ally, in  addition,  early ;  and  even  in  relapses,  after  having  previously 
disappeared,  it  is  likely  to  reappear.  Unfortunately,  the  reaction  is 
present  almost  as  constantly  in  cases  of  acute  tuberculosis,  particularly 
miliary  tuberculosis,  pneumonia,  certain  acute  exanthemata,  malaria, 
and  typhus  fever,  so  that  it  acquires  decisive  significance  with  relative 
rarity. 

More  important  is  the  state  of  the  white  blood-corpuscles  in 
typhoid  fever  (see  p.  172).  Soon  after  the  beginning  of  the  fever,  and 
progressively  from  this  time  on,  there  occurs  an  often  considerable 
reduction  in  the  number  of  white  blood-corpuscles ;  this  does  not  occur 
in  a  number  of  other  diseases  important  in  differential  diagnosis,  but  in 
which,  on  the  contrary,  a  more  or  less  marked  leukocytosis  is  the  rule 
(p.  172).  Also,  the  relative  increase  which  occurs  in  the  large  mononu- 
clear forms  is  occasionally  of  diagnostic  aid. 

When  all  the  symptoms  previously  considered,  especially  the  charac- 
teristic course  of  the  fever-curve  and  the  pulse-curve,  the  peculiar  stools, 
the  enlargement  of  the  spleen,  roseolse,  and  bronchitis,  coexist,  or  even 
if  only  some  of  these  develop  coincidently,  the  diagnosis  is  generally 
easy  and  certain.     If,  however,  only  one  of  these  symptoms  be  present, 


406  TYPHOID  FEVER. 

and  then  in  tm  imcharacteristic  nianiicr,  the  establishment  of  the  diag- 
nosis ^^•ill  generally  require  a  longer  period  of  observation,  and,  above 
all,  will  demand  repeated,  thorough  examinations  directed  to  the  exclu- 
sion of  other  forms  of  disease.  In  not  a  few  eases  in  which  the 
cardinal  symptoms  of  typhoid  fever  do  not  appear  or  are  indefinite, 
careful  comprehensive  investigation  may  provide  the  basis  for  a  com- 
pai'atively  certain  diagnosis  by  exclusion. 

Not  rarely  in  cases  of  obscure  diagnosis  some  sudden  occurrence 
tears  away  the  veil  and  renders  clear  the  existence  of  typhoid  fever. 
Among  such  conditions  are,  especially,  intestinal  hemorrhage, 
which  occurs  at  a  certain  period  of  the  disease,  perforative  perito- 
nitis, and  combinations  of  both.  Kpistaxis  may  also  at  times  be 
considered  indicative  of  existing  typhoid  fever ;  at  least,  it  is  far  less 
likely  to  occur  in  connection  with  s  number  of  other  infectious  diseases, 
which  are,  especially  iu  the  initial  stage,  to  be  taken  into  consideration 
from  the  differential  diagnostic  standpoint.  It  should,  however,  be  borne 
in  mind  that  it  is  likewise  quite  frequent  in  cases  of  miliary  tuberculosis 
and  meningitic  conditions. 

Nervous  impairment  of  hearing,  occurring  at  the  height  of 
the  fever,  and  inflammation  of  the  middle  ear,  developing  some- 
what later,  if  wdth  certainty  preceded  only  by  catarrhal  or  slight  erosive 
affections  of  the  pharynx,  are  of  value  from  a  diagnostic  standpoint. 
Conversely,  a  number  of  individual  symptoms  are  more  or  less  opposed 
to  the  presence  of  tyj)hoid  fever.  Among  these  cory^a  and  con- 
junctivitis especially  may  be  named,  and  jaundice,  which,  in  spite 
of  the  frequent  anatomic  involvement  of  the  larger  biliary  passages, 
develops  with  extreme  rarity.  It  is  noteworthy,  further,  that  the 
occurrence  of  profuse  or  persistent  sweating  at  the  height  of 
the  fever  is  strongly  opposed  to  the  existence  of  typhoid  fever. 

Not  less  than  the  absence  of  characteristic  individual  symptoms, 
the  variability  in  the  course  of  typhoid  fever  may  give  rise  to  difficulty 
in  diagnosis,  and  the  more  so,  naturally,  the  less  clear  the  history  and 
the  shorter  the  period  of  observation.  Thus,  the  fortunately  rare,  rap- 
idly fatal,  fulminant  or  hyperpyretic  cases,  especially  if  the  history  is 
not  suggestive  of  typhoid  fever,  and  if,  with  exception  of  enlargement 
of  the  spleen,  no  striking  symptom  has  developed,  readily  fail  of 
recognition  during  life.  In  the  true  hyperpyretic  cases  especial  difficulty 
is  at  times  created  by  the  mode  of  onset — with  a  chill — and  the  abrupt, 
not  step-like,  ascent  of  the  temperature  to  a  level  that  is  not  at  all  expected 
in  the  course  of  typhoid  fever,  and  least  during  the  first  week. 

Another  form  of  disease,  of  opposite  character  from   the  prognostic 


DIAGNOSIS.  407 

standpoint,  the  abortive  form,  exhibits  a  resemblance  to  the  preceding 
in  some  respects,  namely,  a  similar  ascent  of  the  temperature  at  a  single 
bound,  at  times  after  antecedent  chill,  then  a  sliort,  hij^lily  febrik;  course, 
terminating  in  recovery  with  a  critical  decline,  not  rarely  without  the 
development  of  roseolse,  intestinal  symptoms,  or  even  appreciable 
enlargement  of  the  spleen.  Some  of  the  cases  of  this  character  are 
considered  as  instances  of  central  pneumonia,  or  even  of  ephemera, 
unless  the  prevalence  of  an  epidemic  of  typhoid  fever  or  the  simulta- 
neous occurrence-  of  other  cases  which  are  well-marked  leads  in  the  right 
direction.  That  also  the  remaining  atypical  varieties,  the  true  mild 
and  mildest  cases  of  typhoid  fever,  may  be  a  source  of  great  difficulty 
will  be  obvious  from  the  previous  description  of  their  course.  Not  less 
obscure  may  the  protracted,  otherwise  mild  cases  prove,  especially  if 
attended  with  remittent,  intermittent,  or  irregular  temperature-curves. 

Scarcely  recognizable  at  times  are  ambulatory  and  afebrile  cases  of 
typhoid  fever.  Error  in  diagnosis  in  a  number  of  cases  may  be  due  to 
the  fact  that  thorough  examination  was  not  made,  or  that  this  was  not 
suggested  by  reason  of  extraneous  circumstances.  In  some  cases  roseolae 
and  enlargement  of  the  spleen,  which  occur  also  in  afebrile  cases,  and 
are  scarcely  less  common  in  ambulatory  cases  than  in  others,  would 
otherwise  have  pointed  in  the  right  direction.  I  have  already  mentioned 
that  in  apparently  mild  cases,  in  which  the  patients  walk  to  the  physi- 
cian's office  or  to  the  hospital,  one  is  occasionally  surprised  by  such  a 
discovery. 

In  comparison  with  the  varieties  mentioned,  the  well-marked  hemor- 
rhagic cases  are  much  less  to  be  taken  into  consideration  from  the  diag- 
nostic standpoint.  Fortunately  rare  in  themselves,  they  generally 
exhibit  the  characteristic  symptoms  of  typhoid  fever  at  the  beginning. 
When,  however,  the  case  comes  under  observation  shortly  before  the 
fatal  termination,  with  an  indefinite  history,  it  will  be  wise  to  do  no 
more  than  make  the  diagnosis  of  an  infectious  disease  that  has  become 
hemorrhagic,  but  to  refer  its  explanation  to  the  prevailing  type  of 
epidemic. 

It  should  not  be  forgotten  that  occasionally  a  complication  of  typhoid 
fever  with  ulcerative  endocarditis  and  secondary  multiple  emboli  of  the 
skin  may  give  rise  to  confusion  with  the  true  hemorrhagic  form  ;  and, 
as  has  occurred,  that  essential  septicemic  ulcerative  endocarditis,  if 
attended  with  profound  toxic  eifects  upon  the  central  nervous  system, 
may  be  confounded  with  typhoid  fever. 

It  has  already  been  seen  how  difficult  the  diagnosis  may  become  if 
certain  typhoid  disorders  of  the  viscera  or  actual  compli- 


408  TYPHOID  FEVER. 

cations  dominate  the  picture  of  the  disease  from  the  outset,  if  it  sets 
in  dii'cctly  with  the  local  mauifestations  alone,  while  the  remaining 
symptoms  distinctive  of  typhoid  fever  make  their  appearance  later.  We 
may  mention  at  this  point  the  nephrotyphoid,  pueumotyphoid,  and 
pleurotyphoid,  which  have  alreiidy  been  fully  described.  Far  more 
frequent  than  these  varieties,  and  therefore  quite  noteworthy,  is  meningo- 
typhoid,  which  I  was  the  first  to  study  carefully.  When  it  is  present, 
the  diagnosis  may  be  rendered  all  the  more  difficult  from  the  fact  that 
in  large  cities  isolated  cases  of  typhoid  fever  and  cerebrospinal  menin- 
gitis almost  always  occur  side  by  side.  It  is  also  noteworthy  that  in 
house  endemics  of  typhoid  fever  occasionally  all  the  cases  set  in  with 
meningitic  symptoms. 

The  condition  of  typhoid  perityphlitis  previously  mentioned  may 
also  give  rise  to  error  in  diagnosis  and  serious  injury  to  the  })atient, 
•  especially  when  it  develops  without  antecedent  characteristic  diarrhea, 
or  as  occurs  at  times  even  after  obstinate  constipation.  The  condition 
becomes  almost  beyond  the  possibility  of  diagnosis  when  the  appendicitis 
develops  in  the  course  of  the  mildest  form  or  of  an  ambulatory  attack  of 
typhoid  fever,  and  the  patients,  after  the  symptoms  have  in  large  part 
subsided  and  are  free  from  fever,  are  admitted  into  the  hospital  as 
"  convalescents  from  appendicitis."  Under  such  circumstances  a  relapse 
of  the  typhoid  fever  in  a  well-characterized  form  occasionally  first 
brings  the  desired  explanation.  In  those  cases  in  which  the  patients 
have  been  under  observation  before  the  development  of  the  perityphlitis, 
the  height  and  the  character  of  the  accompanying  fever,  as  well  as  the 
circumstance  that  it  persists  far  beyond  the  period  of  development  of 
the  inflammatory  exudate,  may  lead  to  a  correct  diagnosis. 

Finallv,  there  may  yet  be  taken  into  consideration  in  this  connection 
certain  mixed  infections  that  may  greatly  increase  the  difficulty  of 
recognizing  typhoid  fever  as  the  underlying  cause  of  the  morbid  con- 
dition in  question.  The  most  important  is  the  septicemic  variety  of 
typhoid  fever,  as  well  as  the  combinations  with  malaria  not  rarely 
observed  in  Europe,  the  tropics,  China,  Japan,  and  North  America. 

General  conditions,  personal  as  well  as  those  not  related  to  the  indi- 
vidual, also  have  a  determining  influence  upon  the  diagnosis.  The  role 
of  age  in  this  connection  is  undoubted.  The  conditions  for  a  correct 
diagnosis  are  relatively  most  favorable  during  the  period  of  youth, 
including  late  childhood.  In  early  childhood,  and  especially  during 
infancy,  the  course  of  the  disease  may  in  many  respects  be  so  unusual 
that  its  recognition  is  thereby  rendered  difficult.  It  must  likewise  be 
borne    in  mind  that  the  disease  frequently  pursues   an   abbreviated, 


DIAGNOSIS.  409 

irregular,  unusually  mild  course  in  children  ;  while,  on  the  other  hand, 
their  tendency  to  react  with  considerable  fever  to  slight,  scarcely  appre- 
ciable influences  should  be  remembered.  Not  less  difficulty  often 
attends  the  recognition  of  typhoid  fever  in  advanced  life,  in  conse- 
quence of  the  frequently  uncharacteristic  course  of  the  feve.,  and 
especially  on  account  of  the  almost  or  wholly  afebrile  cases.  In  addi- 
tion, enlargement  of  the  spleen  and  roseolae  are  frequently  distinctly 
less  marked  or  entirely  wanting  in  old  age. 

Almost  in  the  same  way  as  in  the  aged,  cases  modified  by  chronic 
disease  and  constitutional  abnormalities,  as  well  as  by  a 
vicious  mode  of  life,  may  readily  fail  of  recognition. 

It  need  scarcely  be  pointed  out  that  isolated  cases  of  typhoid  fever 
without  demonstrable  connection  with  antecedent  or  simultaneous  cases, 
and  especially  the  primary  cases  in  a  place,  may  be  difficult  of  diag- 
nosis ;  and  that,  conversely,  the  fact  that  typhoid  fever  is  prevalent  in 
a  place  may  throw  light  upon  a  number  of  obscure  cases  of  febrile 
disease. 

Of  great  importance  in  the  diagnosis  naturally  are  the  duration  of 
the  period  of  observation  in  a  case  and  the  period  at  which  it  first 
comes  under  observation.  The  most  favorable  stages  in  the  latter 
connection  are,  doubtless,  the  end  of  the  first  and  the  second  week, 
because  the  development  and  the  combination  of  the  most  characteristic 
signs  occur  at  this  time.  It  is  in  the  second  week  that  the  diagnosis  is 
most  frequently  made  at  first  sight.  The  diagnosis  is  generally  quite 
difficult  at  the  beginning  of  the  first  week.  At  this  time  one  must  be 
governed,  by  reason  of  almost  constant  absence  of  local  symptoms, 
almost  alone  by  the  mode  of  onset  and  the  course  of  the  fever.  It 
should  be  borne  in  mind,  however,  that  even  at  this  time  enlargement 
of  the  spleen  is  occasionally  demonstrable,  and  that,  particularly  during 
some  epidemics,  there  appear  not  rarely  during  the  first  days  of  the 
fever,  and  even  during  the  last  days  of  the  period  of  incubation,  angi- 
nose  symptoms  that  are  peculiar  to  typhoid  fever,  and  which  may  cause 
the  inexperienced  to  confuse  the  condition  with  croup  and  diphtheria. 

The  diagnosis  is  generally  easier  during  the  stage  of  defervescence 
than  duriug  the  first  days  of  the  disease.  It  will  then  usually  be 
known  that  a  febrile  condition  has  preceded,  or  a  portion  thereof 
may  be  observed,  and,  besides,  there  are  likely  to  be  found  residua 
of  roseolae,  developed  sudaminal,  persistent  enlargement  of  the  spleen, 
bronchitis,  hypostases,  and,  finally,  the  characteristic  febrile  course  with 
the  well-known  steep  curves.  In  patients  who  come  under  obser- 
vation   in    the    first  period    after  defervescence,   persistent    subnormal 


410  TYPHOID  FEVER. 

temperature  with  relatively  great  frequency  and  instability  of  the  pulse 
is  indicative  of  an  antecedent  severe  febrile  disease,  ami  in  none  of  all 
these  is  this  symptom  so  frequent  and  so  persistent  as  in  typhoid  fever. 
The  importance  of  the  diagnosis,  especially  after  the  termination  of  the 
actual  disease,  with  regard  to  the  diet  and  permission  to  get  out  of  bed, 
need  only  be  mentioned  at  this  place.  Reference  may  be  made  here 
again  to  the  diagnostic  significance  of  relapses.  Every  experienced 
physician  will  be  able  to  recall  cases  in  which  relapses,  by  their  regular 
typical  course,  cleared  up,  from  the  diagnostic  standpoint,  primary  febrile 
states  which  pursued  an  irregular  course  or  did  not  at  all  come  under 
immediate  observation. 

SPECIAL  DIFFERENTIAL  DIAGNOSIS. 

Having  established  guiding  principles  with  regard  to  individual 
symptoms,  symptom-groups,  and  general  conditions,  we  may  nov/  con- 
sider some  of  the  most  important  diseases  which  may  be  confounded 
with  typhoid  fever.  Few  of  these  are  to  be  taken  into  consideration 
from  the  standpoint  of  differential  diagnosis  throughout  the  entire 
course  of  the  disease,  but  most  of  them,  according  to  their  character 
and  their  manifestations,  are  to  be  considered  only  during  certain 
stages. 

Acute  Miliary  Tuberculosis. — Confusion  of  typhoid  fever  with 
acute  miliary  tuberculosis  is  especially  frequent,  and  vice  versa.  The 
best  diagnosticians  have  made  mistakes  in  this  connection,  or  have 
failed  to  reach  a  definite  conclusion  after  weeks  of  observation,  until 
finally  the  recovery  of  the  patient  proved  the  case  to  be  one  of  typhoid 
fever,  or  post-mortem  examination  showed  it  to  be  one  of  miliary  tuber- 
culosis. The  principal  difficulty  in  the  differential  diagnosis  resides  in 
the  fact  that  both  diseases  often  exist  for  a  considerable  time  without 
conspicuous  local  manifestations,  while  the  disturbances  in  the  general 
condition  due  to  the  action  of  toxins,  the  typhoid  state,  may  be  equally 
developed  in  both.  Both  diseases,  after  an  equal  duration,  are  attended 
with  sopor,  muttering  delirium,  floccitation,  subsultus  teudinum,  and 
finally  coma,  and  are  preceded  by  headache,  vertigo,  languor,  and  often 
nosebleed. 

It  has  been  said  that  the  course  of  the  temperature  is  distinctive  in 
each  disease.  This  may  be  applicable  to  typical  cases  of  typhoid  fever. 
In  protracted  atypical  cases,  however,  the  temperature-curve,  especially 
the  markedly  remittent  or  intermittent  type,  may  greatly  increase  the 
difficulty  of  differentiation  from  miliary  tuberculosis.  Profuse  per- 
sistent sweating  during  the  febrile  stage,  especially  with  an  intermittent 


DIAGNOSIS.  411 

temperature-curve,  is  in  favor  of  miliary  tuberculosis  and  against  typhoid 
fever.  More  important  than  the  state  of  the  temperature  may  be  that 
of  the  pulse,  inasmuch  as  its  relative  slowness,  so  frequently  observed 
in  cases  of  typhoid  fever  in  youthful  individuals,  does  not  occur  in 
cases  of  miliary  tuberculosis,  except  in  tlie  presence  of  a  combination 
with  basilar  meningitis,  which  is  readily  recognizable  from  other 
symptoms.  Marked  dicrotism  of  the  pulse  is  also  incomparably  less 
common  in  cases  of  miliary  tuberculosis. 

The  appearance  of  the  patient  may  alone  be  of  some  importance  to 
the  trained  observer.  In  the  presence  of  miliary  tuberculosis  a  peculiar 
slight,  diffuse  lividity  exists  at  the  height  of  the  disease,  which,  in  com- 
bination with  the  general  pallor,  gives  rise  to  a  characteristic  appear- 
ance, especially  of  the  face  and  the  extremities.  The  state  of  the  spleen 
also  is  noteworthy ;  its  enlargement,  beginning  toward  the  end  of  the 
first  week  of  the  disease  and  progressing  from  this  time  to  the  end  of  the 
second  week,  is  in  favor  of  typhoid  fever ;  while  enlargement  of  the  spleen 
is  much  less  constant  in  the  presence  of  miliary  tuberculosis,  and  is  even 
not  rarely  permanently  absent.  That  small  hyperemic  papular  spots, 
in  general  not  distinguishable  from  roseolse,  may  be  present  also  in 
cases  of  miliary  tuberculosis,  though  rarely  and  in  small  number,  has 
been  previously  mentioned.  A  profusion  of  roseolse  of  typical  develop- 
ment and  distribution  is,  however,  distinctive  of  typhoid  fever. 

I  am  unable  to  agree  unconditionally  with  the  opinion  that  the 
absence  or  the  presence  of  meteorism  is  distinctive.  It  is  true,  flatten- 
ing or  retraction  of  the  abdomen  is  more  frequent  in  cases  of  miliary 
tuberculosis,  especially  if  the  cerebral  membranes  are  also  involved ; 
but,  as  has  already  been  mentioned,  typhoid  fever  also  is  quite  commonly 
unattended  with  noteworthy  meteorism  either  temporarily  or  perma- 
nently. If  it  be  considered,  in  addition,  that  severe  cases  of  miliary 
tuberculosis  may  also,  precisely  like  severe  cases  of  typhoid  fever,  be 
attended  with  marked  distention  of  the  abdomen,  the  diagnostic  value 
of  this  symptom  is  further  diminished. 

With  regard  to  the  diagnostic  significance  of  diarrhea,  it  should  not 
be  overlooked  that  thin  stools  may  occur  also  in  cases  of  miliary  tuber- 
culosis, especially  when  old  intestinal  ulceration  is  present ;  they  may 
even  be  of  a  yellow  color  when  the  diet  is  predominantly  liquid  and  of 
milk.  Constipation  or  regularity  in  the  action  of  the  bowels  is  not 
distinctive  one  way  or  the  other ;  while  intestinal  hemorrhage  occurs 
almost  solely  in  cases  of  typhoid  fever. 

The  symptoms  referable  to  the  Imigs  may  also  increase  rather  than 
diminish  the  difficulty  in  differentiating  the  two  diseases,  particularly  at 


412  TYPHOID  FEVER. 

the  beginning.  Both  are  attended  with  a  dry,  short  cough,  with  scanty, 
macroscopically  wholly  uncharacteristic  expectoration,  and  in  which, 
even  in  cases  of  miliary  tuberculosis,  tubercle-bacilli  are  found  only 
exceptionally,  and  then  are  derived  from  older  ulcerative  foci.  On 
physical  examination,  with  a  normal  percussion-note,  dry  rales,  sibilant 
and  sonorous,  are  generally  present  in  both  diseases.  If,  however,  an 
especially  dense,  fresh  eruption  of  tubercles  in  the  lungs  occurs  in  a 
case  of  miliary  tuberculosis,  highly  characteristic  manifestations  may 
result,  namely,  subjective  dyspnea,  with  far  more  marked  increase  in 
respiratory  frequency  than  occurs  in  cases  of  typhoid  fever  with  a 
similar  range  of  temperature,  and,  at  the  same  time,  acute  pulmonary 
emphysema,  an  especially  decisive  objective  sign,  which  has  hitherto 
received  far  too  little  attention,  and  which  has  rendered  me  excellent 
service  in  many  cases.  This  pulmonary  emphysema  never  occurs,  in 
my  experience,  as  the  result  of  typhoid  bronchitis,  while  it  is  an  almost 
natural,  readily  explicable  result  of  the  direct  or  indirect  occlusion 
of  the  bronchioles  by  a  uniform,  dense,  and  recent  eruption  of  tubercles. 

The  differential  count  of  the  leukocytes  may  be  of  considerable  value 
in  differentiating  these  two  conditions,  in  both  of  which  there  is  a 
decrease  in  the  absolute  number.  But,  while  in  typhoid  fever  there  is 
usually  a  relative  increase  in  the  large  mononuclears,  in  acute  miliary 
tuberculosis  this  does  not  occur. 

One  examination,  finally,  should  never  be  omitted  in  doubtful  cases, 
namely,  that  of  the  eyeground  for  tubercles  of  the  choroid.  It  is  true, 
this  decisive  condition  occurs,  according  to  many  writers  and  my  own 
experience,  only  in  the  minority  of  cases,  and  its  detection  is  often 
rendered  more  difficult  from  the  fact  that  the  nodules  develop  with  a 
certain  degree  of  preference  at  the  periphery  of  the  eyeground. 

Further,  it  should  always  be  borne  in  mind  that  typhoid  fever  may 
be  complicated  by  miliary  tuberculosis.  It  is  true  that  this  generally 
occurs  during  the  later  stages  of  the  disease,  and  even  during  conva- 
lescence. In  the  latter  event,  even  careful  observers,  especially  at  the 
beginning,  will  not  always  be  secure  against  the  possibility  of  mis- 
taking this  for  a  relapse. 

Meningitis. — When  acute  miliary  tuberculosis  is  attended  with 
basilar  meningitis,  the  diagnosis  is  thereby  rendered  rather  easier 
than  more  difficult ;  the  reasons  for  this  need  not  be  given  in  detail 
here.  From  the  beginning,  under  such  circumstances,  the  unusually 
severe  headache,  the  obstinate  vomiting,  especially  after  the  ingestion 
of  food,  are  far  more  indicative  of  impending  meningitis  than  of  typhoid 
fever. 


DIAGNOSIS.  413 

It  need  scarcely  be  repeated  that  in  a  doubtful  case  lumbar  puncture 
often  proves  of  the  greatest  value. 

That  simple  purulent  meningitis,  originating  from  disease 
of  the  nose  or  of  the  middle  ear,  may  now  and  again  give  rise  to 
doubt  and  confusion  need  only  be  briefly  mentioned.  The  conscientious 
physician  will,  apart  from  this,  make  an  examination  of  the  ears  and 
of  the  nasopharynx  in  the  case  of  every  febrile,  soporose  patient,  and 
in  a  suspicious  case  lumbar  puncture  should  be  performed. 

With  regard  to  epidemic  cerebrospinal  meningitis,  and  the 
possibility  of  confounding  it  with  typhoid  fever,  I  may  refer  to  a  pre- 
vious chapter  (pp.  269-274). 

Cryptogenic  Septicemia. — The  differentiation  of  cryptogenic 
septicemia  from  typhoid  fever  may  under  some  circumstances  be  quite 
difficult.  The  quite  usual  development  of  a  typhoid  state,  the  febrile 
course,  which,  precisely  as  in  a  case  of  typhoid  fever,  may  exhibit  the 
curve  of  a  continued  or  a  remittent  fever,  and  the  rarely  absent  enlarge- 
ment of  the  spleen,  are  particularly  confusing  in  this  connection. 
Diffuse  bronchitis  also,  quite  similar  to  that  of  typhoid  fever,  is  not 
rare.  Diarrhea  is  almost  as  inconstant  as  in  cases  of  typhoid  fever. 
Frequently  there  is  slight,  at  times  even  marked,  jaundice,  which  will 
then  be  strongly  indicative  of  septicemia.  In  these  cases  blood-cultures 
are  often  of  decisive  diagnostic  value. 

Other  Septic  Processes. — An  answer  to  the  question  whether 
puerperal  septicemia  or  typhoid  fever  is  present  may  under  some 
circumstances  be  attended  with  greater  difficulty  than  would  be  believed. 
On  one  hand,  especially  when  the  history  is  indefinite,  severe  puerperal 
septicemia  of  typhoid  course  may  be  mistaken  for  actual  typhoid 
fever ;  and,  on  the  other  hand,  it  should  always  be  borne  in  mind  that 
pregnant  women  attacked  with  typhoid  fever  quite  generally  suffer  from 
abortion  and  premature  labor.  Undor  such  circumstances  it  has  re- 
peatedly happened  that  the  continuation  of  the  typhoid  disease  was 
looked  upon  as  septicemia  in  connection  with  supposed  primary  prema- 
ture labor.  I  have  personally  observed  cases  in  which  the  history  and 
the  clinical  conditions  were  so  obscure  that  only  the  appearance  of  dis- 
tinct roseolse,  or  even  serum-diagnosis,  cleared  up  the  condition. 

Ulcerative  endocarditis,  which  has  been  mentioned  repeatedly, 
and  is  to  be  considered  among  the  septic  processes,  is  also  generally 
attended  with  symptoms  of  the  typhoid  state,  and  not  at  all  rarely  with 
recent  enlargement  of  the  spleen.  Nevertheless,  the  embolic  lesions  of 
the  skin  that  occur  will  not  readily  be  confounded  with  the  t^^hoid 
roseolae,    especially   as  other  emboli,    recognizable   without   difficulty, 


414  TYPHOID  FEVER. 

generally  occur  in  the  retina,  the  brain,  the  kidneys,  and  the  lungs. 
Naturally,  the  acute  devel()])ment  of  a  cardiac  affection,  with  debility, 
irregularity,  and  murmurs,  will  not  readily  be  overlooked.  The  onset 
may  occur  when  the  heart  was  previously  intact,  or — ^and  this  renders 
recognition  of  the  condition  more  difficult — it  may  complicate  previous 
valvular  lesions.  The  diagnosis  will  be  facilitated  if  it  be  borne  in 
mind  that  endocarditis  (not  septic)  is  extremely  rare  as  a  complication 
of  typhoid  fever,  and  that  myocarditis  also  is  by  no  means  frequent ; 
and  that  both  occur,  if  at  all,  generally  at  the  height  or  toward  the  end 
of  severe  cases — at  a  period,  therefore,  when  it  has  generally  been  possi- 
ble to  make  the  diagnosis  of  typhoid  fever  with  certainty. 

In  youthful  persons  infectious  osteomyelitis — designated  by 
French  investigators  (Chassaignac)  especially  as  *'  typhe  epiphysaire " 
— is  not  rarely  the  cause  for  error  in  diagnosis.  In  such  persons,  with 
an  obscure  febrile,  typhoid  symptom-complex,  dependence  should  never 
be  placed  upon  the  absence  of  complaints  referred  to  the  extremities,  but 
these  should  always  be  examined  carefully  for  edema,  livid  redness,  and 
circumscribed  tenderness,  especially  the  epiphyseal  regions  of  the  long 
meduUated  bones. 

Intoxications. — Doubtless,  intoxication  from  the  ingestion  of 
decomposed  organic  substances  (meat,  fish,  mussels)  and  fluids  (water, 
milk,  etc.)  contaminated  by  the  products  of  putrefaction  also  gives 
rise  to  acute  intestinal  disorders  with  "typhoid"  symptoms.  The 
inhalation  of  putrid  gases  also  appears  to  be  capable  of  giving  rise  to 
diarrhea,  with  enlargement  of  the  spleen,  fever,  and  stupor,  as  is  shown 
by  many  reports  in  the  literature,  among  which  are  the  well-known 
instances  in  England  previously  mentioned  (p.  50),  which  at  the  time 
of  their  publication  were  exploited  as  supporting  the  pythogenic  theory 
of  typhoid  fever  (p.  20). 

Malaria. — Malaria  generally  will  give  rise  to  difficulty  in  diagnosis 
only  in  those  regions  in  which  the  cases  present  remittent  or  continued 
fever.  Error  may  under  such  circumstances  be  made  in  either  direc- 
tion, inasmuch  as,  on  the  one  hand,  malarial  processes  may  be  mistaken 
for  typhoid ;  and,  on  tlie  other  hand,  fulminant  typhoid  fever  may  be 
mistaken  for  pernicious  malaria.  That  rare  cases  of  ambulatory  typhoid 
fever  with  intermittent  fever  and  chills  may  under  certain  conditions 
simulate  malaria  has  already  been  mentioned.  Examination  of  the 
blood  for  malarial  parasites  usually  clears  up  the  diagnosis  without 
difficulty  in  these  cases. 

Influen^ja. — The  confusion  of  influenza  and  typhoid  fever  is  occa- 
sionally pardonable.     The  high  fever,  the  prostration,  and  the  stupor  of 


DIAGNOSIS.  415 

the  patients,  and  other  severe  nervous  general  manifestations,  may  con- 
tribute to  this  end.  It  is  important  in  this  connection  to  obtain  a 
history  of  the  beginning  of  the  disease.  In  cases  of  influenza  the 
initial  coryza,  with  which  are  soon  associated  laryngotracheitis  and 
bronchitis,  will  not  readily  be  overlooked.  In  cases  of  typhoid  fever 
coryza  is,  as  has  been  mentioned,  an  extremely  rare  condition,  and 
affections  of  the  larynx,  as  well  as  bronchial  catarrh,  generally  do  not 
make  their  appearance  before  the  second  week,  or  even  later.  Besides, 
enlargement  of  the  spleen  is  usually  wanting  in  cases  of  influenza,  while 
the  roseola,  or  an  exanthem  resembling  it,  is  never  observed. 

The  Acute  Kxanthemata. — Among  the  diseases  that  practically 
never  give  rise  to  difficulty  in  the  differential  diagnosis  at  the  height 
of  their  development,  but  do  so  all  the  more  frequently  in  the  initial 
stage,  are  the  acute  exanthemata.  Scarlet  fever  and  variola  particularly, 
and  also  measles  during  the  primary  fever,  may  be  responsible  for 
such  error  in  young  nervous  individuals.  Apart  from  the  knowledge 
of  the  prevalence  of  the  one  or  the  other  of  the  diseases  in  question, 
the  local  initial  symptoms  that  are  soon  added  to  the  ill-defined  general 
febrile  state  will  soon  serve  as  a  guide  to  the  careful  observer.  With 
regard  to  measles,  importance  is  to  be  attached  to  conjunctivitis  with 
coryza  and  catarrh  of  the  upper  air-passages,  and  with  regard  to  scarlet 
fever,  to  the  distinctive  angina ;  while  in  cases  of  small-pox,  the  char- 
acteristic sacral  pain,  as  well  as  the  initial  exanthemata,  particularly 
the  scarlatiniform,  in  the  triangles  of  the  thighs  and  the  upper  arms, 
and  the  appearance  of  the  variolous  efflorescence  upon  the  pharyngeal 
mucous  membrane  immediately  afterward,  at  times  almost  simultane- 
ously, will  lead  in  the  right  direction.  At  a  later  period  varioloid,  with 
a  scanty  eruption  accidentally  confined  to  the  trunk,  may  at  most  be  a 
source  of  doubt.  If  it  be  borne  in  mind,  however,  that  the  variolous 
eruption  almost  unexceptionally  appears  first  upon  the  face  also  in  cases 
of  varioloid,  that  constantly  with  its  appearance,  even  in  the  severest 
cases,  decline  of  temperature  takes  place,  one  will  seldom  be  seriously 
embarrassed. 

Typhus  Pever. — The  differential  diagnosis  may  be  far  more  diffi- 
cult with  regard  to  typhus  fever.  This  is  exhibited  historically  in  the 
fact  that  the  two  diseases  were  not  properly  distinguished  from  each 
other  up  to  the  middle  of  the  nineteenth  century".  Even  at  the  present 
day  the  conditions  are  not  very  simple  in  coimtries  and  at  times  in  which 
both  diseases  are  constantly  prevalent  side  by  side,  and  it  is  precisely 
under  such  circumstances  that  early  and  accurate  diagnosis  is  of  impor- 
tance with  regard  to  the  interests  of  the  community.     If  a  decision  be 


416  TYPHOID  FEVER. 

desired  in  the  first  few  days  of  the  disease,  it  may  be  almost  impossible 
if,  iu  addition  to  the  febrile  "  typhoid  "  state,  the  distinctive  cutaneous 
manifestations  have  not  yet  developed.  It  should,  besides,  always  be 
noted — what  the  inexperienced  readily  overlook — that  even  in  quite 
severe  cases  of  typhus  fever  the  development  of  the  associated  eruption 
may  be  extremel}'  imperfect  or  almost  completely  absent.  In  the 
presence  of  a  marked  exanthem  in  connection  with  both  diseases,  the 
differentiation  is  easy  for  an  experienced  observer.  The  typhoid  roseola 
is  almost  from  the  beginning  slightly  elevated,  papular,  and,  throughout 
its  entire  duration,  purely  hyperemic,  constantly  circular,  and  sharply 
defined.  On  the  other  hand,  the  spots  of  typhus  fever  are  less  sharply 
limited  and  are  ill  defined ;  at  first  pale,  the  majority  soon  become  hem- 
orrhagic, so  that  they  are  then  simple,  not  elevated,  spots  of  from  a 
dusky,  coppery  redness,  only  in  part  disappearing  on  pressure,  to  a 
dark  livid  color,  which  then  distinctly  exhibit  their  petechial  character. 

The  diagnosis  is  facilitated  by  the  fact  that  the  spots  of  typhus 
fever  appear  earlier  than  the  typhoid  roseola — between  the  second  and, 
at  the  latest,  the  fifth  day  of  the  disease — and  they  rapidly  attain  their 
definitive  development  singly  and  collectively  at  a  single  stroke,  inva- 
riably without  recrudescences,  within  from  forty-eight  to  seventy-two 
hours.  The  differences  in  the  distribution  of  the  eruptions  over  the 
surface  of  the  body  in  both  diseases  are  also  noteworthy.  While  in 
cases  of  typhus  fever  the  trunk  and  the  extremities  are  quite  uniformly 
covered,  in  cases  of  typhoid  fever  only  the  parts  of  the  extremities  adja- 
cent to  the  trunk  are  involved,  and  the  remaining  portions  are  involved 
in  lesser  degree  the  further  removed  they  are  from  the  trunk.  In  cases 
of  typhus  fever,  when  the  exanthem  is  developed  to  any  considerable 
degree,  especially  the  forearms  and  the  legs  are  preferably  involved,  and 
also  the  dorsum  of  the  hands  and  the  feet,  so  that  I  advise  careful 
inspection  of  these  parts  when  there  is  suspicion  as  to  the  presence  of 
this  disease.  With  regard  to  the  face,  there  is  a  certain  degree  of  agree- 
ment between  the  two  diseases,  in  so  far  as  in  the  vast  majority  of  cases 
of  typhus  fever  this  also  is  likely  to  remain  free  from  the  exanthem. 
On  the  other  hand,  the  face  in  the  latter  disease  exhibits  a  number  of 
other  distinctive  features.  Even  from  the  beginning  it  is  diffusely  red 
and  turgid,  the  conjunctivae  are  vividly  injected,  subsequently  often 
ecchymotic,  while,  in  addition,  the  face  has  a  wild  and  startled  expres- 
sion, which  is  in  marked  contrast  to  the  indifferent,  dull  expression  of 
the  typhoid  patient. 

Not  less  important  than  observation  of  the  skin  in  the  differentia- 
tion of  the  two  diseases  is  the  course  of  the  fever.     In  contrast  with 


DIAGNOSIS.  4]  7 

the  familiar  step-like  ascent  in  cases  of  typhoid  fever,  the  temperature 
in  cases  of  typhus  fever  generally,  after  one  or  rarely  several  chills, 
rises  rapidly  to  its  height  with  slight  interruption,  so  that  within  from 
twenty-four  to  thirty-six  hours  a  level  of  from  40.5°  to  41°  C.  is 
reached — a  far  higher  level  than  in  cases  of  typhoid  fever  at  this  time, 
or  even  in  cases  of  not  unduly  excessive  severity,  throughout  the  entire 
fastigium.  The  further  course  of  the  fever  also  exhibits  important 
differences  that  cannot  be  considered  fully  at  this  point.  Its  total  dura- 
tion does  not  exceed  from  fourteen  to  seventeen  days  even  in  the  most 
severe  cases  of  typhus  fever.  It  generally  terminates  with  a  critical  or 
a  rapid,  step-like  decline.  With  the  abrupt  onset  and  the  rapid  ascent 
of  the  fever  to  a  considerable  height  corresponds,  in  cases  of  typhus 
fever,  also  the  far  earlier  appearance  of  the  severe  general  manifesta- 
tions, with  the  unusual  prostration  that  compels  the  patient  to  take  to 
his  bed  as  early  as  the  first  or  the  second  day.  The  other  profound  dis- 
turbances referable  to  the  nervous  system  also  appear  much  earlier  than 
in  cases  of  typhoid  fever.  As  early  as  the  first  days  furious  delirium 
often  occurs ;  and  from  the  beginning  of  the  second  week,  profound 
coma. 

The  pulse  in  all  cases  of  typhus  fever,  without  reference  to  age  and 
sex,  is  exceedingly  frequent  from  the  beginning.  In  women  and  children 
it  may  be  120  and  more  during  even  the  first  days  ;  also,  in  previously 
healthy  young  men  a  frequency  of  pulse  is  sometimes  encountered  at 
the  beginning,  such  as  is  rarely  observed  at  the  height  of  the  disease  in 
cases  of  typhoid  fever.  Enlargement  of  the  spleen  is  far  less  constant 
in  cases  of  typhus  than  in  those  of  typhoid  fever.  When  it  occurs,  it 
develops  earlier  and  it  subsides  more  quickly.  I  have  generally  observed 
it  to  disappear  during  the  middle  of  the  second  week,  and  rarely  to 
persist  beyond  the  period  of  defervescence.  Meteorism  develops  only 
exceptionally  in  cases  of  typhus  fever,  while  one  must  expect  the  occur- 
rence of  diarrhea  at  the  height  of  the  disease,  and  the  stools,  under 
the  influence  of  the  food  administered,  may  even  acquire  an  appearance 
similar  to  those  in  cases  of  typhoid  fever.  With  regard  to  the  diazo- 
reaction,  there  appears  to  be  no  difference  between  the  two  diseases. 
Also,  in  cases  of  typhus  fever,  which  differs  in  this  as  in  many  other 
conditions  from  the  acute  exanthemata,  the  diazo-reaction  is  generally 
demonstrable  at  the  beginning  and  at  the  height  of  the  fever.  It  may 
be  mentioned  that  the  leukocytes  are  usually  increased  in  number  in 
this  condition. 

Relapsing"  IPever. — Confusion  with  relapsing  fever  is  more 
likely  to  occur  with  regard  to  typhus  fever  than  with  regard  to  typhoid 

27 


418  TYPHOID  FEVER. 

fever.  Only  the  early  cases  in  an  epidemic,  and  these  only  during  the 
first  few  days,  could  cause  doubt.  Here  and  there,  it  is  true,  confusion 
of  the  second  paroxysm  of  relapsing  fever  with  a  relapse  of  typhoid 
fever  might  arise,  especially  if  the  first  paroxysm  failed  to  come  under 
cliuical  observation.  Even  in  such  a  case  the  disease  cannot  readily 
be  confounded  with  typhoid  fever.  Its  onset  with  a  chill,  the  imu- 
sually  high  temperature — uj)  to  41°  C.  and  above — reached  within  a 
short  time,  the  critical  decline  at  the  end  of  seven  days,  rarely  later, 
protect  against  error.  Naturally,  the  demonstration  of  the  spirilla  of 
relapsing  fever,  if  this  be  thought  of  in  the  earliest  cases  of  an  epidemic, 
and  which,  as  is  known,  can  be  found  during  the  entire  febrile  period, 
and  even  for  one  or  two  days  beyond  (Birch-Hirschfeld),  will  remove 
all  doubt. 

Secondary  Syphilis. — The  confusion  of  the  eruptive  stage  of 
secondary  syphilis  with  typhoid  fever  is  more  likely  to  arise  at  times 
than  would  be  believed.  The  best  observers  have  made  mistakes  in 
this  connection  when  the  exanthem  of  secondary  syphilis  has  made  its 
appearance  with  remittent  fever,  enlargement  of  the  spleen,  and,  in  irri- 
table individuals,  even  with  general  nervous  symptoms,  stupor,  etc. 

Trichinosis  may,  in  mild  cases,  with  predominant  gastro-entcritic 
symptoms,  quite  readily  be  confounded  Avith  irregular,  moderately  severe 
cases  of  tvphoid  fever.  In  the  presence  of  severe  trichinosis,  the  pain- 
ful tumefaction  and  induration  of  the  muscles,  the  flexor  contractures 
of  the  extremities,  the  edema,  especially  of  the  face,  will  permit  of  a 
decision  without  difficulty.  As  a  final  resort,  removal  of  a  piece  of 
muscle  for  diagnosis  would  be  indicated. 

Anthrax,  if  unattended  with  carbuncle  or  edema,  in  the  form  of 
intestinal  mycosis,  with  the  attendant  symptoms  of  enteritis,  intestinal 
hemorrhage,  and  the  typhoid  state,  might  exceptionally  cause  difficulty 
in  diagnosis. 

Acute  glanders  also  is  suggestive  at  first  sight  of  typhoid 
fever  if  the  patients  exhibit  remittent  fever,  a  dry,  fissured  tongue, 
and  fuliginous  deposits  upon  the  lips  and  the  gums.  Generally,  how- 
ever, the  characteristic  impetiginous  or  ecthymatous  eruptions,  multiple 
abscesses  of  the  muscles,  or  specific  ulcerative  lesions  of  the  mucous 
membranes  mil  lead  to  a  correct  diagnosis. 

The  diagnostic  relations  of  pneumonia  and  pleurisy  to  typhoid 
fever  have  been  sufficiently  discussed  at  various  places.  At  this  point 
it  mav  onlv  be  mentioned  that  those  rare  cases  of  central  pneumonia,  or 
at  least  pneumonia  beginning  at  the  center  of  the  lung,  may  at  times 
give  rise  to  confusion,  and  particularly  if  they  are  attended  with  stupor 


DIAGNOSIS.  419 

and  delirium,  without  pleuritic  pain,  and  if,  in  consequence  of  impaired 
consciousness  or  debility,  their  nature  is  not  disclosed  by  characteristic 
expectoration. 

BACTERIOLOGIC  DIAGNOSIS. 

The  expectation  generally  held,  after  the  discovery  of  the  typhoid- 
bacillus,  that  the  diagnosis  of  the  disease  would  be  made  by  the  demon- 
stration of  the  organism  in  every  case,  which  many  thought  would  be 
a  relatively  simple  procedure,  has,  in  the  original  sense,  scarcely  been 
realized.  On  the  contrary,  it  may  be  said  that  the  difficulties  attending 
the  direct  demonstration  of  the  bacilli  in  the  patient  or  his  dejections 
are  considerable,  and  in  some  cases  at  present  unsurmountalde. 

Differentiation  of  Bacillus  typhosus  from  Bacillus  coli. 
— The  differentiation  of  the  typhoid  bacillus  isolated  from  the  excreta 
of  the  patient,  from  suspicious  fluids,  articles  of  food,  etc.,  from  other 
micro-organisms,  especially  from  those  belonging  to  the  colon-group,  is 
still  so  difficult  that  even  at  the  present  day  some  observers — a  very 
small  number,  it  is  true — still  maintain  the  opinion  that  the  two  are 
identical. 

As  a  matter  of  fact,  the  great  morphologic  and  biologic  resemblance 
between  the  two  structures,  especially  with  regard  to  their  form  and  size, 
their  motility,  as  dependent  upon  the  presence  of  flagella,  their  negative 
response  to  Gram's  method  of  staining,  and  their  equally  remarkable 
resistance  to  carbolic  acid,  which,  when  added  to  the  nutritive  medium  in 
amounts  up  to  0.25  per  cent.,  does  not  prevent  their  development,  is  a 
source  of  no  small  difficulty.  In  addition,  a  great  difficulty  in  the  isolation 
of  the  organism  arises  from  the  abundant  presence  of  micro-organisms  of  the 
colon-group  in  the  stools,  and  their  tendency  to  invade  all  possible  internal 
organs.  Numerous  points  of  difference  believed  to  be  reliable  have  been 
laid  down  as  the  result  of  many  hundreds  of  investigations,^  but  not  a  few 
of  these  differences  were  very  quickly  shown  to  be  inconstant. 

The  following  are  at  present  considered  among  the  more  valuable 
criteria :  The  flagella  are  said  to  be  more  numerous  and  longer  in  the 
typhoid-bacillus  than  in  the  micro-organisms  of  the  colon-group ;  in  the 
hanging  drop,  with  suitable  precautions,  typhoid-bacilli  are  believed  to  be 
more  active  and  to  preserve  their  motility  for  a  longer  time.  While  the 
characteristics  of  the  growth  upon  gelatin  and  agar  exhibit  slight,  at  times 
scarcely  demonstrable,  differences,  the  results  of  culture  upon  "potatoes  are 
frequently  more  characteristic  (Gaffky).  It  was  formerly  stated  that  if  one- 
half  of  a  disk  of  boiled  potato  be  inoculated  with  the  typhoid-bacillus  and 
the  other  half  with  the  colon-bacillus,  there  will  develop  upon  the  latter, 
after  a  certain  period  of  time,  a  dense,  distinctly  visible,  at  first  yellowish, 
then  grayish-brown,  moist,  glistening,  smeary  coating,  while  the  growth  of 

'  See  Losener,  Arbeiten  aus  dem  Reichs-Gesundheitsamte,  Bd.  xi.,  one  of  the  most 
comprehensive  critical '  papers  upon  the  subject  of  the  differentiation  of  the  typhoid- 
bacillus. 


420  TYPHOID  FEVER. 

the  typboid-hacillu?  upon  the  other  lialf  appears  only  as  an  extremely  deli- 
cate, moist,  almost  transparent  deposit,  so  thin  that  at  times  it  can  be  lifted 
up  with  a  needle  only  in  the  form  of  most  delicate  filaments,  if  at  all.  It 
is  now  known,  however,  that  these  differences  may  be  minimized,  or  even 
entirely  disappear,  with  certain  varieties  of  colon-bacilli,  and  that  they 
depend  largely  also  upon  the  reaction  of  the  potato,  so  that  the  test,  there- 
fore, is  not  of  great  use. 

Some  other  cultural  characteristics  are  undoubtedly  to  be  considered  as 
more  trustworthy,  especially  the  growth  in  litmus  milk.  While  the  colon- 
bacillus  causes  the  milk  to  become  ra]iidly  and  extremely  acid  and  to 
undergo  coagulation,  the  typhoid-bacillus  does  not  cause  coagulation  of  the 
milk  and  renders  it  only  very  faintly  acid,  even  if  it  be  kept  in  the  ther- 
mostat for  weeks.  The  glucose-test  is  not  less  valuable.  If  of  two  (best, 
hermetically  sealed)  fermentation-flasks  containing  grape-sugar-bouillon,  the 
one  is  inoculated  with  the  typhoid-bacillus  and  the  other  with  the  colon- 
bacillus,  and  both  are  exposed  for  twenty -four  hours  to  a  temperature  of 
27°  C,  active  fermentation,  with  the  evolution  of  gas,  will  develop  in  the 
latter,  while  this  does  not  occur  in  the  other  flask.  The  fermentation-test 
becomes  more  striking  if  made  with  solid  nutritive  media.  Of  two  glucose- 
agar  or  glucose-gelatin  tubes,  the  one  inoculated  with  the  typhoid-bacillus 
remains  unchanged,  while  the  active  evolution  of  gas  induced  in  the  other 
by  the  colon-bacillus  elevates  the  gelatin  from  the  bottom  of  the  tube  and 
causes  rents  and  fissures  to  appear  in  the  media. 

In  addition  to  the  milk-test  and  the  fermentation-test,  the  negative 
response  to  the  indol-test,  for  which  Kitasato '  has  described  a  most  useful, 
simple  method,  appears  to  be  quite  reliable.  In  general,  the  colon-bacillus 
yields  the  reaction,  while  it  is  wanting  with  the  typhoid-bacillus.  But,  since 
Peckham  -  has  shown  that  by  particular  methods  of  cultivation  the  typhoid- 
bacillus  may  be  made  to  produce  indol,  and,  on  the  other  hand,  that  unless 
the  colon-bacillus  be  grown  on  an  absolutely  sugar-free  medium  the  develop- 
ment of  indol  may  be  ])revented,  the  method  must  be  considered  of  question- 
able value,  and  is  useful  only  when  taken  in  connection  with  other  features. 

More  important  than  any  of  these  tests  in  the  differentiation  of  the 
typhoid-bacillus  is  its  specific  reaction  to  the  blood-serum  of  immune  animals 
and  of  typhoid  patients.  The  use  of  this  method  (which  will  be  more  fully 
discussed  later  in  considering  its  application  to  diagnosis  of  the  disease) 
as  a  means  of  bacteriologic  differentiation  we  owe  especially  to  Gruber  and 
Durham,  who  appreciated  its  full  value,  and  who  worked  out  fully  the  con- 
ditions under  which  it  may  be  applied.  While  doubt  has  been  thrown  on 
its  value  as  a  means  of  differentiation  by  several  observers,  who  also  demand 
the  use  of  extremely  high  dilutions  of  the  serum — even  1  :  100,000  and  over 
— it  may  be  said  that  when  the  serum,  even  in  moderate  dilutions,  is  con- 
trolled by  observation  of  its  action  on  known  typhoid-bacilli,  the  test  is  quite 
constant  and  extremely  valuable.  It  must  be  emphasized,  however,  that 
no  one  test  is  sufficient  for  the  determination  of  the  nature  of  an  organism 
of  this  group,  and  that  only  wdien  all  the  various  characteristics  and  results 
of  different  tests  are  taken  into  consideration  can  a  definite  conclusion  be 
reached.  Unfortunately,  numerous  earlier  statements  with  regard  to  the 
presence  of  the  typhoid-bacillus  in  the  living  body  and  its  excreta  have 
been  made  without  consideration  of  this  rule,  and  are  therefore  valueless. 

Attention  should  again  be  called  to  the  possibility  of  the  occurrence  of 
'  Centralhl.  f.  Baki.  u.  Parasit.,  Bd.  xiv.,  No.  22. 
'  Jour,  of  Exp.  Med.,  vol.  ii. 


DIAGNOSIS.  421 

diseases  presenting  the  clinical  picture  of  typhoid  fever,  hut  which,  as  demon- 
strated by  blood-cultures  and  agglutination-test,  are  probably  caused  not  by 
the  typhoid-bacillus,  but  by  closely  related  organisms,  the  so-called  paracolon 
or  paratyphoid-bacilli.  Such  bacilli  have  been  described  by  Widal,* 
Gwyn,'^  Gushing,^  and  Schottmiiller.*  Other  bacilli  intermediate  between 
the  typhoid  and  colon  groups  are  of  the  hog-cholera  or  Bacillus  enteritidis 
(Gartner)  type.  A  careful  comparative  study  of  these  intermediate  forms 
has  been  made  by  Gushing.^  The  bacillus  of  dysentery,  the  so-called  Shiga's 
bacillus,  is  also  very  closely  related,  morphologically  and  culturally,  to  the 
typhoid-bacillus  ;  the  exact  relationship  between  the  two  organisms  has, 
however,  not  been  completely  worked  out. 

Blood-cultures. — Up  to  within  the  past  year,  cultures  from  the 
circulating  blood  have  been  of  little  aid  in  diagnosis.  As  has  been  pre- 
viously stated  (p.  175),  newer  work  with  better  methods  has  made 
possible  the  demonstration  of  the  typhoid-bacilli  in  the  circulating  blood 
in  70  to  80  per  cent,  of  all  cases  examined.  Cole,  working  at  the 
Johns  Hopkins  Hospital,  has  lately  isolated  the  bacilli  from  43  of  58 
cases  examined.  In  many  of  the  cases  the  cultures  were  obtained  early 
in  the  disease,  before  a  positive  Widal  test  had  been  obtained.  In 
certain  cases  the  culture  alone  established  the  diagnosis,  which  had  pre- 
viously been  doubtful  or  even  unsuspected.  The  method  used  is  as 
follows  :  ^  The  skin  over  the  anterior  surface  of  the  patient's  arm  at  the 
bend  of  the  elbow  is  carefully  sterilized.  To  obtain  the  blood,  a  syringe 
holding  8  to  10  c.c,  and  fitted  with  a  small  needle  which  will  readily 
enter  one  of  the  superficial  veins,  is  used.  By  using  a  small  needle  and 
entering  the  vein  with  one  thrust  little  or  no  pain  is  caused.  From  8  to 
10  c.c.  of  blood  are  withdrawn  and  divided  among  five  or  six  Erlenmeyer 
flasks,  each  containing  150  c.c.  of  bouillon.  The  flasks  are  then  shaken 
and  placed  in  the  incubator,  and  after  twenty-four  hours,  if  cloudy,  agar 
plates  are  made.  Usually,  the  organisms  in  the  bouillon  are  some^vhat 
clumped,  at  least  sluggishly  motile,  and  so  are  not  suitable  for  trying 
the  serum-reaction.  The  diagnosis  of  Bacillus  typhosus  in  each  case 
should  be  decided  only  by  typical  growth  on  all  media  and  by  agglu- 
tination-test with  known  typhoid  serum.  Frequently,  a  fairly  definite 
conclusion  can  be  reached  in  thirty-six  hours  after  obtaining  the  culture. 
If  the  bacilli  grow  out  in  the  bouillon  in  twenty-four  hours,  they  can  be 
transferred  at  once  to  the  various  media,  and  from  the  slant  agar,  after 
six  to  eight  hours,  a  suspension  in  bouillon  can  be  made  in  which  the 
serum-reaction  can  be  tried. 

^  La  Semaine  Med.,  Aug.  4,  1897.  ^  Johns  Hopkins  Hosp.  Bull.,  vol.  ix. 

.'  Ibid.,  vol.  xi. 

*  Deutsch.  med.  Woch.,  Aug.  9,  1900;  also,  Zeit.  f.  Hyg.  u.  Inf.,  Bd.  xxxvi.,  H.  3. 
^  Loc.  cit.  8  Johns  Hopkins  Hosp.  Bull.,  No.  VH,  vol.  xii. 


422  TYPHOID  FEVER. 

Although  the  method  presents  considerable  technical  difficulties, 
■where  the  conditions  are  such,  as  in  a  h()spital,  that  it  inav  be  employed, 
it  is  of  undoubted  aid  in  diapKtsis. 

Cultures  from  Rose-spots. — As  ])reviously  stated  (p.  175), 
cultures  made  from  the  rose-spots  have  shown  the  presence  of  the 
typhoiil-baoillus  in  a  majority  of  the  cases.  The  procedure  is  not 
readily  applicable  as  a  means  of  diagnosis,  however,  on  account  of  the 
discomfort  to  the  patient,  and  also  because,  in  the  cases  in  which  well- 
developed  rose-spots  are  present,  the  diagnosis  is  usually  already  clear. 

Also  puncture  of  the  spleen  durinu;  life  (Lucatello,  Chantemesse 
and  Widal,  Kcdtenbacher,  E.  Xeisser),  whicli  undoubtedly  frequently 
yields  positive  results  (p.  176),  has  lost  all  significance  as  a  practically 
applicable  method,  as  it  exposes  the  patients  directly  to  danger.  That 
in  some  cases  lumbar  puncture — which  is  often  indicated  even 
therapeutically — may  facilitate  the  diagnosis  is  entirely  probable,  and 
has  been  verified  by  illustrative  cases. 

Especial  hope  was  attached  from  the  outset  to  examination  of 
stools.  It  was  soon  recognized  that  the  typhoid-bacilli  (see  p.  32) 
usually  leave  the  body  of  the  patient  in  the  stools,  and  that  they  are 
demonstrable  in  these  generally  from  the  begiuning  or  the  middle  of  the 
second  week  of  the  disease  to  the  fourth  and  even  the  fifth  week,  less 
commonly  into  the  period  following  defervescence.  Their  demonstra- 
tion was  from  the  outset  attended  with  the  greatest  difficulty,  on 
account  of  the  immense  number  of  other  micro-organisms  at  the  same 
time  present,  and  especially  those  of  the  colon-group.  Eisner '  has 
introduced  the  use  of  a  special  medium  for  this  purpose  which  has  given 
good  results  in  his  hands,  and  has  been  warmly  recommended  by 
Brieger,^  Lazarus,^  and  others ;  but,  on  the  other  hand,  has  been 
declared  by  others  (Breuer,^  Haedke  ^)  as  not  entirely  reliable.  How- 
ever this  may  be,  the  procedure  requires  the  greatest  skill,  so  that  while 
in  the  hands  of  the  trained  observer  it  is  applicable  to  the  solution  of 
certain  problems,  in  its  present  form  it  has  no  future  as  a  clinical 
method. 

Eisner's  method,  briefly,  is  as  follows  :  If  1  per  cent,  of  iodin  is  added 
to  sterilized  potato-gelatin  of  definite  acidity,  and  if  plates  are  made  after 
addition  of  the  fecal  matter  to  he  examined,  it  is  possible,  by  the  addition 
of  the  iodin.  to  exclude  from  development  all  other  micro-organisms  hut  the 
colon-bacillus  and  the  typhoid-bacillus.  In  addition,  the  latter  develops 
distinctly  more  slowly  and  incompletely.      While  in  the  course  of  twenty- 

>  Zeit.f.  Hyg.  u.  Infektionsk.,  1895.  Bd.  xxi. 

2  Deutsch.  med.   Woch.,  1895,  No.  50.         =*  Berlin,  klin.   Woch.,  1895,  JSTo.  49. 

■*  Ibid.,  1896,  No.  47.  *  Deutsch.  med.   Woch.,  1897,  No.  2. 


DIAGNOSIS.  423 

four  hours  nothing  of  the  typhoid-bacillus  can  be  seen  with  the  naked  eye 
and  with  low  powers  of  the  microscope,  after  the  lapse  of  fjrty-eight  hours 
it  will  be  present  together  with  the  colon-bacillus,  from  which  it  is  readily 
distinguishable  upon  the  plate.  In  addition  to  the  large,  much  more  mark- 
edly granular,  brown-colored  colonies  of  the  latter,  those  of  the  former 
appear  as  small,  bright,  glistening,  extremely  finely  granular  points,  resem- 
bling drops  of  water. 

Within  the  past  few  years  other  media  and  special  methods  have 
been  introduced  by  numerous  observers.  Tlie  most  promising  of  these 
methods  are  those  of  Piorkowski,  Remy,  and  Hiss.  Each  of  these 
methods  has  given  good  results  in  the  hands  of  its  author.  Hiss,  using 
his  method,  was  able  to  isolate  the  typhoid-bacillus  from  17  out  of  21 
cases  in  the  febrile  stage.  It  still  remains  to  be  seen  whether  the  gen- 
eral routine  application  of  these  methods  is  practicable  or  not. 

As  previously  stated  (see  pp.  34  and  190),  typhoid-bacilli  are  found 
in  the  urine  in  about  one-third  of  the  cases  examined.  While  their 
presence  is  rare  before  the  third  week,  they  may  occur  during  the  second 
week,  or  even  the  end  of  the  first  week,  and  so  their  isolation  may  be 
of  definite  diagnostic  value.  In  making  cultures,  females  should  be 
catheterized  under  careful  antiseptic  precautions,  and  the  urine  so 
obtained  should  be  plated  at  once.  In  males,  the  anterior  urethra 
should  be  irrigated  with  antiseptic  solutions,  and  the  patient  should  then 
void  mto  a  sterile  flask.  In  the  determination  of  a  bacillus  obtained  in 
the  culture,  great  care  should  be  taken  against  confounding  the  typhoid- 
bacillus  with  the  colon-bacillus,  to  which  cystitis  is  quite  commonly  due. 
Attention  should  again  be  called  to  the  peculiar  shimmer  described  by 
Horton-Smith  which  is  seen  when  a  test-tube  filled  with  urine  containing 
large  numbers  of  bacilli  is  held  up  to  the  light  and  gently  shaken.  In 
this  way  the  presence  of  the  condition  can  often  be  predicted  before 
cultures  have  been  made. 

METHODS  OF  SERUM-DIAGNOSIS, 
Within  the  past  few  years  an  indirect  method  of  bacteriologic  diag- 
nosis has  been  introduced  which  has  proved  to  be  of  great  value. 
While  this  method  of  serum-diagnosis,  owing  to  the  frequently  delayed 
appearance  of  the  reaction,  has  not  been  found  to  be  of  so  great  value 
as  was  at  first  hoped,  it  is,  nevertheless,  an  exceedingly  important  factor 
in  diagnosis.  This  method  is  based  upon  the  fundamental  investiga- 
tions of  R.  Pfeiffer  ^  and  his  pupils,  originally  undertaken  in  the  study 
of  the  question  of  immunity.  These  investigators  studied  the  action 
of  the  blood-serum  of  animals  immunized  to  cholera  and  typhoid  fever 

'  Zeit.  f.  Hyg.  u.  Infektionsk. ,  Bd.  xix. 


424  TYPHOID  FEVER. 

upon  the  respective  pathogenic  micro-organisms.  They  showed  espe- 
cially (Pfeiffer  and  Kolle  ^)  that,  exactly  as  in  the  case  of  cholera,  the 
serum  of  animals  immunized  to  typhoid  fever,  when  placed  in  the 
abdominal  cavity  of  a  previously  healthy  experimental  animal  (guinea- 
pig),  together  with  an  amount  of  typlioid  culture  experimentally  deter- 
mined to  be  fatal,  not  alone  protected  this  animal  against  tlic  action  of 
the  bacilli,  but  also  inducetl  granular  degeneration  of  the  latter,  and 
finally  their  complete  solution. 

The  Pfeiffer  I^ysogenic  Action  of  the  Immune  Serum. — 
After  the  Pfeiffer  school  had  with  certainty  demonstrated  this  "lyso- 
genic  "  action  of  the  immune  serum  to  be  specific,  it  made  the  important 
advance  of  establishing  the  procedure,  not  alone  as  one  important  in  its 
bearing  on  the  question  of  inmi unity,  but  also  as  a  most  available 
method  of  differentiation  of  micro-organisms,  particularly  of  the 
typhoid-bacillus  from  the  members  of  the  colon-group,  which  had 
hitherto  been  done  by  direct  culture-methods  only  with  much  difficulty, 
and  then  not  with  certainty. 

A  further  noteworthy  advance  in  this  direction  consisted  in  the 
demonstration,  inaugurated  by  earlier  investigations  of  Pfeiffer  and  his 
pupils,"  Metschnikoff",^  Bordet,'*  and  others,  that  the  reaction  of  Pfeiffer, 
at  first  believed  to  occur  only  in  the  body  of  the  living  animal,  could 
be  obtained  also  under  certain  conditions  in  the  test-tube. 

The  Method  of  Gruber. — The  introduction  of  the  method  into 
practice  was  effected  finally  through  the  important  labors  of  Gruber  and 
his  pupils,"  who  furnished  evidence  that,  in  the  same  way  as  the  blood- 
serum  of  an  immunized  animal,  that  of  a  human  being,  after  recovery 
from  tvphoid  fever,  brought  together  with  a  culture  of  typhoid-bacilli  in 
a  test-tube,  soon  renders  the  bacilli  immobile  and  causes  them  to  aggre- 
gate in  the  form  of  clumps  and  to  be  precipitated  in  the  form  of  a 
flocculent  sediment  (agglutination).  Pfeiffer  and  Kolle  ^  had,  inde- 
pendently of  Gruber,  obtained  similar  results. 

In  the  historic  consideration  of  the  entire  question,  it  is  of  importance  that 
Gruber  at  once  emphasized  the  fact  that  his  method  of  agglutination  estab- 
lished not  alone  the  differentiation  of  the  typhoid-bacillus  from  similar 
bacilli,  hut  that  it  was,  furthermore,  capable  of  furnishing,  directly  from 
the  blood-serum  of  a  human  being,  proof  of  the  previous  existence  of 
typhoid  fever  ;  thus,  of  making  the  diagnosis  subsequently  or  of  confirming 
it  if  already  made  clinically.     Therefore  to  Gruber,  and  with  him  to  his 

1  Zeit.  f.  Hyg.  u.  Infekfimisk.,  Bd.  xxi.         =  Issaeff  and  Ivanoff.  Ihid.,  Bd.  xvii. 
=*  Annales  de  I'Instihd  Pasteur,  1895.  '  Ibid.,  1895. 

»  Wien.  klin.   Woch.,  1896,  Nos.  11  and  12.      (Gruber  and)  Durham,  Proceedings 
of  the  Royal  Society,   January  3,   1896,  vol.  lii. 
6  Deutsch.  med.   Woch.,  1896,  No.  12. 


DIAGNOSIS.  425 

pupil,   Griinbaum/  belongs  the  credit  of   having  called  attention   to   the 
diagnostic  utility  of  serum-examination. 

Although  Gruber's  method  was  at  first  only  retrospective,  it  was 
elaborated  by  Widal  ^  in  so  far  as  he  furnished  proof  that  the  serum 
removed  exhibited  the  same  agglutinating  infiueuce,  not  alone  after 
recovery  from  typhoid  fever,  but  also  in  the  beginning  and  at  the  height 
of  the  disease.  Accordingly,  it  is  possible  to  establish  the  existence  of 
the  disease  directly  by  means  of  serum-diagnosis,  not  alone  subsequently, 
but  also  during  its  progress. 

After  Widal's  elaboration  of  the  doctrine  of  Gruber  had  received  abun- 
dant confirmation  in  France  (Chantemesse,  Dieulafoy,  Lemoine,  Achard, 
Catrin,  Menetier,  and  Sinedey,  Widal  and  his  pupils),  his  statements  led  to 
the  inception  of  a  number  of  investigations  also  in  Germany.^  With  slight 
differences  in  detail,  these  agreed  with  the  results  of  Gruber  and  Widal 
and  contributed  materially  to  the  further  development  and  simplification  of 
the  method. 

The  Widal  Serum-diagnosis. — The  Widal  serum-examination 
as  generally  practised  at  present,  and  as  it  has  been  serviceable  also  in 
my  clinic  in  a  large  number  of  cases,  is  carried  out  in  the  following 
manner  : 

Blood-abstraction. — The  blood  is  abstracted  either  directly  from 
the  median  vein  of  the  patient  to  be  examined,  by  means  of  a  sterilized 
hypodermic  syringe  or  by  the  application  of  a  cupping-glass  after  a 
number  of  incisions  have  been  made  into  the  skin.  Smaller  amounts 
of  blood  from  the  tip  of  the  finger,  or,  better  still,  from  the  lobule  of 
the  ear,  which  are  quickly  sent  to  the  laboratory  in  a  sterile  culture- 
tube  of  considerable  size,  are  adequate  in  private  practice.  The  blood 
obtained  is  introduced  into  a  narrow  test-tube,  which  is  then  placed 
obliquely  for  sedimentation.  If  this  does  not  take  place  completely,  so 
that  the  serum  overlying  the  blood-clot  still  contains  red  blood-corpus- 
cles, this  will  not  interfere  with  the  further  investigation,  as  even  dried 

1  Sitzungsb.  d.  Wiesbadener  Congress,  f.  inn.  Med.,  April,  1896,  and  the  Lancet, 
Sept.  19,  1896. 

^  Sem.  med.,  1896,  No.  33.  Compare  also  Widal's  historic  description.  Munch, 
med.  Woch.,  1897,  No.  8.  Keports  of  the  remaining  French  investigations  are  con- 
tained in  Sem.  med.,  1896,  from  August  to  November. 

^Breuer,  Berlin,  klin.  Woch.,  1896,  Nos.  47  and  48.  Stern,  Centralbl.  f.  inn. 
Med.,  1896,  No.  49,  and  1897,  No.  11.  Haedke,  Deutsch.  med.  Woch.,  1897,  No.  2. 
C.  Frankel,  Deutsch.  med.  Woch.,  1897,  Nos.  8  and  16.  Jez,  Wien.  med.  Woch.,  1897, 
No.  3.  Pick,  Wien.  klin.  Woch.,  1897,  No.  4.  Kolle,  Deutsch.  med.  Woch.,  1897, 
No.  9.  Gruber,  Munch,  med.  Woch.,  1897,  No.  17.  Levy  and  Gissler,  Munch,  med. 
Woch.,  1897,  Nos.  50  and  51.  Du  Mesnil  de  Kochemont,  Miinch.  med.  Woch.,  1898, 
No.  5.     E.  Frankel,  Ibid. 


426  TYPHOID  FEVER. 

blood   retains   its   agglutinating    power   and   may   be   employed    in   an 
emergency '    (Widal,   Stern   and   Forster,   J()hnst<tn). 

Macroscopic  Method. — If  some  of  the  serum  tluis  obtained  is 
transferred  by  means  of  a  platiimni  loop  to  several  cubic  centimeters 
of  typhoid  bouillon-culture,  preferably  not  more  than  twelve  hours  old, 
in  a  narrow  test-tube,  and  if  the  mixture  be  exposed  to  a  temperature 
of  37°  C,  in  the  course  of  from  three  to  seven  hours  the  formation  of 
flakes  and  fragments  begins  to  take  place  in  the  previously  uniformly 
turbid  fluid,  and  these  soon  settle  to  the  bottom.  At  the  end  of  twenty- 
four  hours  this  separation  of  the  flocculi  from  the  fluid  will  be  com- 
pleted, so  that  the  bouillon  overlying  the  crumbling  yellowish  sediment 
will  have  become  entirely  clear  and  have  regained  its  original  color. 
Microscopic  examination  discloses  that  the  sediment  consists  solely  of  the 
degenerated  and  coherent  bacilli. 

For  the  beginner,  this  test  becomes  especially  distinctive  if,  together  with 
the  inoculated  culture,  one  is  prej)ared  to  which  serum  has  not  been  added, 
and  which  then,  in  consequence  of  the  undisturbed  and  persisting  active 
motility  and  uniform  distribution  of  the  bacilli,  retains  its  primary  turbidity. 

Microscopic  Method. — The  macroscopic  procedure  is  useful  only 
as  a  preliminary  test.  It  is  more  convenient  and  more  certain  to  per- 
mit the  process  of  agglutination  to  take  place  beneath  the  microscope, 
when  the  entire  procedure,  which  takes  place  in  the  course  of  a  few 
minutes,  can  be  viewed  in  detail  and  directly.  Widal  employed  this 
procedure,  and  in  the  hands  of  subsequent  observers  it  has  been  greatly 
perfected. 

The  simplest  mode  of  procedure  consists  in  adding  the  serum  to  be 
tested  to  a  bouillon-culture  of  from  ten  to  not  more  than  eighteen  hours 
old,  and  studying  the  hanging  drop.  If  the  serum  is  derived  from  a 
typhoid  patient,  especially  at  the  height  of  the  febrile  stage  or  a  later 
period,  and  if  a  sufficient  amount — ^about  an  equal  part — of  serum  has 
been  added,  the  bacilli  will  be  seen  immediately  after  the  admixture  to 
become  immobile  and  to  collect  in  clumps  of  varying  size.  While  the 
entire  field  of  vision  remains  uniformly  occupied  by  the  swarming  bacilli 
in  a  control-preparation  to  which  no  serum  has  been  added,  that  to 
which  immune  serum  has  been  added  exhibits  large  areas  of  the  visual 
field  that  are  clear,  with  the  agglutinated  clumps  collected  only  in  certain 
places. 

1  Naturally,  as  will  appear  from  what  follows,  if  dried  blood  is  to  be  employed  for 
purposes  of  exact  determination,  its  amount  should  be  measured  before  it  is  dried,  and 
before  beine:  made  use  of  it  should  be  mixed  with  an  accurately  determined  amount 
of  physiologic  salt  soluticm. 


DIAGNOSIS.  427 

For  clinical  purposes  the  microscopic  procedure  has  entirely  dis- 
placed the  macroscopic,  especially  because  it  alone  is  capable  of  ful- 
filling the  recognized  necessary  requirement,  namely,  the  determina- 
tion of  the  greatest  degree  of  dilution  of  the  serum  that  in  a  given  case 
will  lead  to  the  occurrence  of  agglutination. 

The  Barliest  Appearance  of  the  Reaction. — In  his  earliest 
publications  Widal  stated  that  the  agglutinating  action  of  the  serum  of 
typhoid  patients  could  be  elicited  as  early  as  the  end  of  the  first  week 
of  the  disease.  Unfortunately,  this  statement  has  not  been  wholly  con- 
firmed. On  the  contrary,  it  was  found  with  growing  experience  that 
the  serum  acquired  that  property  only  in  the  minority  of  cases  before 
the  termination  of  the  first  week,  most  frequently  not  until  the  second 
week  (from  the  seventh  to  the  tenth  day),  while  rarely  it  was  delayed 
beyond  that  time,  even  to  later  weeks  (Stern,  Kolle,^  Blumenthal  ■^). 
Complete  absence  of  the  reaction  is  one  of  the  rarest  exceptions. 
Among  a  large  number  of  cases,  in  only  two,  which  were  shown 
by  autopsy  to  be  instances  of  typhoid  fever,  have  I  failed  to  observe 
an  undoubted  reaction.  Nevertheless,  it  should  be  borne  in  mind  that 
the  absence  of  agglutination  during  the  first,  and  even  in  the  beginning 
of  the  second  week,  is  not  evidence  against  the  existence  of  typhoid 
fever,  and  that  in  order  to  obtain  reliable  results  the  examination  should 
be  repeated  also  during  the  further  course  of  the  disease  at  definite 
intervals  of  not  too  great  length. 

Specificity  of  the  Reaction. — Naturally,  the  question  soon 
arose  whether,  as  a  matter  of  fact,  the  blood-serum  of  typhoid  patients 
alone  possessed  the  agglutinating  influence  on  the  typhoid-bacillus,  and, 
if  this  be  not  the  case  exclusively,  whether  this  property  might  not 
be  possessed  exceptionally  and  in  lesser  degree  by  serum  from  other 
patients  suffering  from  other  diseases.  It  was  soon  found  that  the 
reaction  occurs  even  during  health  (Stern*)  and  in  the  presence  of  a 
number  of  diseases,  apparently  especially  in  acute  infectious  diseases, 
so  that  for  a  time  the  diagnostic  value  of  the  procedure  appeared  to  be 
diminished  by  this  fact.  On  further  investigation,  however,  it  was 
found  that  under  these  conditions  the  reaction  takes  place  only  when 
comparatively  large  quantities  of  the  serum  to  be  examined  are  added 
to  the  culture. 

Since  Widal' s  first  publication  thousands  of  examinations  have  been 
directed  to  this  point,  and  all  have  yielded  approximately  like  results.  It 
has  been  found  that  the  occurrence  of  agglutination  with  equal  parts  of 

1  CentralU.f.  inn.  Med.,  1896,  No.  49.  ^  Deufsch.  med.   Woch.,  1897,  No.  9. 

8  Ibid.,  1897,  No.  15.  ^  Centralbl.  f.  inn.  Med.,  1896,  No.  49. 


428  TYPHOID  FEVER. 

serum  and  culture,  eveu  one  of  seruin  to  ten  of  culture,  is  of  itself  not 
conclusive  of  typhoid  fever ;  and  further,  that  the  development  of  the 
reaction  with  a  dilution  of  one  to  twenty,  even  one  to  thirty  and  one  to 
forty,  may  also  occur  under  other  conditions ;  while  a  positive  reaction 
with  a  dilution  of  the  serum  beyond  one  to  forty  occurs  almost  exclu- 
sively in  cases  of  typhoid  fever,' 

Gruber  aud  Griinbaum '  and  Stern '  were  among  the  first  to  direct  atten- 
tion to  this  distinctively  important  aspect  of  the  question  ;  and,  after  them, 
especially  Breuer,  C.  Friinkel,  Du  Mesnil,  and  Fdrster.*  That  also  mixt- 
ures above  1  :  20  up  to  1  :  40  are  not  certainly  indicative  of  typhoid  fever 
has  i)eeu  shown  especially  by  van  Ordt/  Kiihnau,*  Ziemke/  SchefTer,'*  and 
others.  According  to  my  own  observations,  such  high  dilutions  of  the 
serum  are  but  rarely  effective  in  the  presence  of  other  infectious  diseases. 

Stern  ^  had  previously  published  the  exact  results  of  examinations  in 
70  cases  of  other  diseases,  and  subsequently,  in  conjunction  with  Sklower,'"  in 
100  cases.  Among  the  latter  there  were:  25  in  which  a  response  to  1  :  10 
was  obtained  ;  10  in  which  a  response  to  1  :  20  was  obtained  ;  2  in  which  a 
response  to  1  :  30  was  obtained  ;  1  in  which  a  response  to  1  :  40  was  obtained. 

Diagnostic  Significance  of  the  Quantitative  Relations 
of  Serum  and  Culture. — From  the  foregoing  the  important  conclu- 
sion can  be  drawn  that  the  diagnostic  utility  of  the  Gruber-Widal  reac- 
tion is  dependent,  above  all  things,  upon  a  careful  consideration  of  the 
quantitative  relations.  The  smaller  the  amount  of  serum  necessary  for 
the   development   of  the   reaction,   the  more  certain   is   the   diagnosis. 

Thus  it  has  been  found,  on  further  study  of  the  condition,  that  at 
times  the  reaction  may  be  obtained  with  almost  incredibly  high  dilu- 

1  The  methods  for  the  exact  preparation  and  the  quantitative  determination  of  the 
mixture  of  serum  and  culture  cannot  be  fully  described  here,  but  they  must  be  learned 
practically.  The  directions  are  carefully  stated  by  A.  Frankel,  Berlin,  klin.  Woch., 
1897,  No.  11,  and  by  Stern,  Centralbl.  f.  inn.  Med.,  1896,  No.  49.  The  latter  obtained 
especially  delicate  results,  which,  however,  are  not  necessary  for  clinical  purposes,  with 
the  aid  of  the  capillary  pipet  of  Gowers.  It  may  be  mentioned  here  that  quite  accu- 
rate results,  quite  sufficiently  so  for  clinical  purposes,  may  be  obtained  by  the  use  of 
small  glass  capillary  pipets,  manufactured  by  drawing  out  small  pieces  of  ordinary 
glass  tubing  in  the  flame.  One  or  more  drops  of  the  serum  are  dropped  from  one  of 
these  pipets  into  a  dish,  and  then  from  the  same  pipet  a  sufficient  number  of  drops  of 
sterile  water  or  salt  solution  are  added  to  make  a  dilution  of  one-half  the  required 
degree.  If,  then,  with  the  platinum  loop  one  drop  of  this  mixture  be  added  to  one 
drop  of  the  bouillon-culture  obtained  with  the  same  platinum  loop,  a  quite  accurate 
dilution  is  obtained.  This  method  has  been  in  use  at  the  Johns  Hopkins  Hospital  and 
has  proved  quite  satisfactory.  The  other  methods,  as  well  as  a  complete  discussion  of 
the  whole  procedure  and  a  review  of  the  literature,  have  been  given  by  Cabot  in  his 
book.  "The  Serum-diagno-sis  of  Disease." 

'  Loc.  cit.  3  7^oc   cit.  ■*  Zeit.  f.  Hyg.  u.  Infektionsk.,  1897,  Heft  3. 

6  Mimch.  med.   Woch.,  1897,  No.  5.  «  Berlin,  klin.   Woch.,  1897,  No.  12. 

'  DeuUch.  med.  Woch.,  1897,  No.  15.         «  Berlin,  klin.   Woch.,  1897,  No.  11. 

'  Loc.  cit.  "  Diss.,  Leipsic,  1898. 


DIAGNOSIS.  429 

tions — 1  :  3000  or  5000,  and  in  a  case  of  Widal's,  even  1  :  20/JOO. 
For  clinical  purposes  such  dilutions  are  wholly  unnecessary.  Gener- 
ally, I  confine  myself  to  dilutions  of  from  1  :  60  to  1  :  100,  and 
after  abundant  experience  I  have  every  reason  to  be  satisfied  therewith. 
Nevertheless,  I  have  frequently  seen  the  reaction  occur  with  dilutions 
of  from  1  :  400  to  1  :  600  and  above,  often  even  when  tlie  reaction 
occurs  within  a  short  time.  The  time  elapsing  before  the  reac- 
tion occurs,  as  just  mentioned,  is  an  equally  important  factor  in  the 
diagnostic  employment  of  the  reaction.  The  shorter  the  action  of  the 
serum,  in  order  to  obtain  a  complete  reaction,  the  more  certain  is  the 
diagnosis,  even  when  low  dilutions  are  employed. 

As  a  result  of  the  foregoing,  the  principle  has  in  the  course  of  time 
developed  in  the  clinical  application  of  the  method  of  dispensing 
with  higher  dilutions  and  demanding  instead  proportionately  greater 
rapidity  in  the  onset  of  the  reaction.  If,  as  happens  so  frequently, 
cessation  of  motility  and  aggregation  in  clumps  take  place  with  light- 
ning-like rapidity  on  addition  of  the  serum,  a  diagnosis  of  typhoid 
fever  may  be  made  with  great  probability  when  dilutions  of  1  :  30, 
often  even  with  dilutions  of  1  :  20,  are  employed.  With  dilutions  of 
from  1  :  40  to  1  :  50  error  will,  according  to  my  experience,  rarely  be 
committed.  Should  the  reaction  not  occur  at  once  with  such  dilutions, 
the  observation  should  be  continued  for  a  longer  time,  and,  with  a  view 
to  greater  certainty,  with  the  further  addition  of  serum  (lesser  degrees 
of  dilution). 

In  his  admirable  paper  upon  the  sources  of  error  in  serum-diagnosis, 

Stern  ^  suggests  a  coutinuation  of  the  observation  for  as  loDg  as  two  hours, 
with  progressively  increasing  dilutions.  Although  this  has  yielded  him  im- 
portant results,  such  a  period  of  observation  is,  according  to  our  experience, 
no  longer  necessary  for  clinical  purposes,  in  view  of  the  present  methods 
and  the  skill  usually  possessed  by  the  observers.  In  my  clinic  our  observa- 
tions do  not,  as  a  rule,  extend  beyond  from  fifteen  to  thirty  minutes,  and 
they  are  made,  as  seems  to  me  quite  sufficient,  at  room-temperature.  That 
the  procedure  of  Stern  may  be  employed  in  cases  in  which  a  decision  is  of 
especial  importance  is  a  matter  of  course. 

It  seems  quite  important  that  some  definite  rule  be  made  in  regard 
to  dilution  and  time  limit  which  should  keep  in  view  the  widest  possi- 
ble application  of  the  method  to  clinical  purposes  and  yet  carefully 
guard  against  errors.  For  several  years  at  the  Johns  Hopkins  Hos- 
pital a  standard  of  dilution  of  1  :  50  and  a  maximum  time  hmit  of  one 
hour  have  been  employed  and  have  given  complete  satisfaction.  It  is 
required  that  complete  agglutination  be  obtained  within  these  limits, 

^Berlin,  klin.   Woch.,  1897,  No.  11. 


430  TYPHOID  FEVER. 

in  order  that  the  reaction  be  considered  positive.  While  with  these 
standards  it  quite  commonly  occurs  that  a  positive  reaction  is  not 
obtained  until  late  in  the  disease,  if,  on  the  other  hand,  they  were  made 
any  less  rigid,  experience  has  shown  that  occasionally  a  positive  result 
would  be  obtained  in  cases  not  typhoid. 

Among  the  sources  of  error  in  serum-diagnosis,  the  important  obser- 
vation should,  in  conclusion,  be  considered  that  the  agglutinating 
action  of  the  serum  may  persist  for  mouths  and  even  years  after  recov- 
er\'  from  the  attack  of  typhoid  fever  (Lichtheim,  C.  Friinkel,  Stern). 
As  a  result,  it  miglit  hapj)en  that  in  the  case  of  a  patient  not  suffering 
from  typhoid  fever,  but  exhibiting  fever  from  some  other  cause,  the 
Gruber-AVidal  reaction  occurring  in  consequence  of  on  antecedent  but 
not  existent  attack  of  typhoid  fever  might  lead  to  error.  The  possible 
defence  that  the  history  would  afford  protection  from  such  an  error  is 
invalidated  by  tlie  fact  that  mild  cases  of  typhoid  fever  which  yield  the 
reaction  equally  with  severe  cases,  not  rarely  remain  doubtful  or  wholly 
imrecognized. 

Prognostic  Significance. — Finally,  an  effort  has  been  made  to  ascribe 
to  the  serum-reaction  a  proguostic,  as  well  as  a  diagnostic,  importance,  inas- 
much as  Catrin  ^  believed  that  he  observed  a  direct  relationship  between 
the  rapidity  and  the  intensity  of  the  Widal  reaction  and  the  severity  of  the 
individual  case.  This  statement  has  already  been  contradicted  by  Stern, 
with  whom  I  am  disposed  to  agree  as  a  result  of  personal  experience. 

1  Sem.  med.,  1896,  No.  62. 


IV.   THE    PROPHYLAXIS   OF  THE    DISEASE 

The  measures  for  the  prevention  of  the  disease  may  be  divided  into 
three  main  groups  : 

1.  General,  which  are  directed  to  the  protection  of  the  inhabitants 
of  entire  districts,  cities,  or  less  extensive  collections  of  dwellings,  against 
the  disease ;  or,  if  it  has  developed,  to  prevent  its  dissemination. 

2.  Special  individual  measures,  by  means  of  which  the  immediate  or 
mediate  transmission  of  typhoid  fever  to  those  who  come  in  contact 
with  the  patient,  or  even  to  remote  distances,  is  prevented. 

3.  Preventive  inoculation,  by  means  of  which  an  attempt  is  made 
to  render  the  person  inoculated  immune  to  the  disease. 

For  the  principles  underlying  the  following  statements  reference 
should  be  made  to  the  chapter  on  Etiology,  and  particularly  to  the  con- 
cluding sentences  thereof  (pp.  77,  78). 

GENERAL  MEASURES. 
By  reason  of  the  ubiquity  of  typhoid  fever,  the  persistence  of  its 
exciting  agent,  and  the  character  and  the  activity  of  intercourse  at  the 
present  day,  the  danger  of  the  dissemination  of  the  disease  by  the  sick 
or  by  intermediary  agents,  especially  infected  articles — beverages,  arti- 
cles of  food,  linen,  articles  of  clothing,  etc. — cannot  wholly  be  pre- 
vented. In  almost  all  places  of  considerable  size,  even  in  those  with 
the  best  sanitary  administration,  the  disease,  at  least  with  regard  to 
individual,  undoubtedly  in  part  imported,  instances,  never  becomes 
wholly  extinct.  In  view  of  the  impossibility  of  preventing  this,  the 
principal  effort  of  public  sanitation  should  be  directed,  by  means  of 
intelligent  and  adequate  measures,  to  the  restriction  of  the  preservation 
and  dissemination  of  the  exciting  agent   emanating  from  the  patient. 

REGULATIONS  OF  THE  SEWAGE-CONDITIONS. 
By  far  the  most  important  general  measure  is  the  appropriate  regu- 
lation of  the  sewage-conditions  and  the  provision  of  a  hygienically 
unobjectionable  and  abundant  water-supply.  That  public  attention 
should  also  be  given  to  the  maintenance  of  the  greatest  possible  degree 
of  salubrity  of  the  dwellings  and  their  surroundings,  as  well  as  hygi- 
enic supervision  of  the  community  in  general,  is  a  matter  of  course,  and 
will  be  referred  to  in  detail  subsequently. 

431 


432  TYPHOID  FEVER. 

The  removal  of  refuse  from  inhabited  places  has  in  view,  in  accord- 
ance with  present  conceptions  bearing  on  the  ])revention  of  tyj)hoid 
fever,  the  certain  removal  of  the  germs  derived  from  typhoid  patients, 
and  thus  their  withdrawal  from  any  direct  or  indirect  influence  upon 
healthy  persons.  In  addition  to  the  urine  and  tho  stools,  refuse  water 
especially  is  to  be  taken  into  consideration  in  this  connection.  Above 
all  other  things,  care  should  be  tiiken  that  none  of  these  are  permitted 
to  remain  in  badly  devised,  pervious  cesspools  and  dung-pits  in  the 
neighborhood  of  human  habitations,  or  is  conveyed  to  adjacent  unused 
land  or  gains  entrance  into  gutters,  or  even  into  water-ways  which  serve 
directly  as  a  source  of  the  water  used  by  the  community  for  drinking 
and  for  domestic  purposes. 

lu  accordauce  with  the  size  and  particular  conditions  of  a  city,  the  arrange- 
ments for  the  drainage  may  be  variable.  While  this  can  generally  be 
secured  in  large  cities  only  by  means  of  appropriate  flush-sewers  with  irri- 
gating fields,  less  commonly  by  conveyance  into  large  water-courses,  for 
smaller  and  the  smallest  cities  the  provision  of  a  combination  of  removal 
and  flushing  systems  (separation  of  the  solid  and  liquid  refuse  matters  and 
removal  in  various  waysj,  or  even  the  tun-system  or  the  pit-system,  will  be 
entirely  adequate. 

WATER-SUPPLY. 

Almost  still  more  important,  in  combination  with  the  system  of 
sewage  adapted  to  the  local  conditions,  is  the  provision  of  an  abun- 
dant supply  of  unobjectionable  water.  li  has  already  been  seen  that 
water,  in  the  various  forms  in  which  it  is  employed — as  drinking- 
water,  as  an  addition  to  articles  of  food  and  beverages,  and  as  used  for 
cleansing  purposes  on  a  large  scale — constitutes  by  far  the  most  common 
medium  for  the  dissemination  of  the  disease  which  needs  to  be  taken 
into  consideration.  Of  how  little  service  even  the  best  system  of  drain- 
age and  sewage  and  the  resulting  purification  of  the  soil  may  be,  when 
it  is  associated  with  an  unsuitable  and  directly  injurious  water-supply, 
has  been  shown  by  the  events  at  Hamburg  previously  mentioned 
(pp.  44,  45). 

An  important  requirement  of  a  really  good  water-service  is  an  unin- 
terrupted supply,  in  such  abundance  that  if  possible  a  distinction 
need  not  be  made  between  drinking-water  and  less  reliable  water  for 
domestic  purposes.  Apart  from  the  fact  that  abundant  opportunity  for 
infection  is  afforded  through  water  used  for  domestic  purposes  (cleansing, 
rinsing,  washing,  and  bathing),  the  prevention  of  its  use  for  drinking 
purposes  appears  practically  entirely  illusory.  In  the  determination  of 
the  character  of  water  from  an  e]Mdemiologic  standpoint,  biologic  exam- 
ination is  of  great  direct,  and  chemic  examination  of  rather  indirect^ 


PBOFIIYLAXIS.  433 

significance.  The  latter  fiiriiislies  tlie  chemic  basis  for  the  suspicion  of 
organic  contamination,  while  by  means  of  the  former  the  presence  of 
bacteria  in  general  in  the  water  is  established,  and  even  at  times  the 
demonstration  of  typhoid-bacilli  can  be  directly  made. 

In  order  to  provide  an  irreproachable  supply  of  water  for  drinking  and 
domestic  purposes  it  will  be  necessary,  in  case  it  shall  be  obtained  from  wells, 
that  the  excavation  shall  be  sufficiently  deep,  and  that  the  walls,  particularly 
in  the  upper  portions,  shall  be  rendered  impervious  to  the  entrance  of  infected 
water  from  the  upper  layers  of  the  adjacent  soil  by  means  of  suitable  masonry 
and  cementing. 

The  water  derived  from  springs — of  as  deep  a  source  as  possible — should 
be  conveyed  through  impervious  tubes  directly  to  the  place  where  it  is  used 
with  all  practicable  avoidance  of  contact  with  the  external  world.  Especial 
care  should  be  directed  to  the  certainty  of  imperviousness  of  the  conduits 
for  spring-water,  from  the  prophylactic  standpoint,  and  naturally,  also,  in 
connection  with  epidemiologic  investigations.  Water  that  is  primarily  the 
best,  if  not  adequately  protected  in  the  course  of  its  distribution,  may  become 
a  source  of  danger  owing  to  contamination  from  its  surroundings — pits, 
infected  superficial  layers  of  soil,  direct  communication  with  cesspools,  admix- 
ture of  rain-water  and  melted  ice  and  snow,  and  all  other  possible  sources 
of  accidental  contamination.  The  history  of  typhoid  fever  exhibits  a  large 
number  of  smaller  and  larger  epidemics  developed  in  this  manner  (pp. 
42,  43). 

When  the  water-supply  of  a  place  must  be  obtained  from  open  water- 
ways, rivers,  brooks,  or  from  seas  and  ponds,  the  water,  before  being  admitted 
into  the  dwellings,  should  be,  in  its  entirety,  subjected  to  trustworthy  proc- 
esses of  filtration  that  can  be  constantly  controlled  biologically  and  chem- 
ically. The  introduction  of  unfiltered  water  into  cities,  with  dependence 
upon  subsequent  sterilization  in  the  houses,  is  absolutely  untrustworthy,  as 
numerous  examples,  especially  again  that  of  Hamburg,  have  shown.  It 
has  already  been  seen  how  uncertain  and  serious  may  become  the  question 
of  house-filters,  and  how  they  not  rarely  are  actually  a  cause  for  further 
pollution  of  the  water.  If  the  use  of  suspected  w^ater  is  absolutely  not  to  be 
avoided,  boiling  and  preservation  in  clean  vessels  should  be  practised.  This 
applies  not  only  to  drinking-water,  but  to  all  water  employed,  particularly 
that  used  for  rinsing,  bathing,  and  washing.  The  use  of  artificial  mineral 
waters  in  suspicious  places  and  in  times  of  epidemic  will  be  serviceable  only 
when  there  is  certainty  that  they  have  been  prepared  from  sterile  water, 
and  that  thorough  cleansing  of  the  bottles  has  been  practised.  That  the 
addition  to  infected  water  of  tea,  coffee,  or  alcoholic  beverages  in  ordinary 
amount  cannot  materially  improve  matters  has  long  been  known.  Typhoid- 
bacilli  may  retain  their  vitality  even  in  ice,  as  has  been  pointed  out,  for  a 
considerable  length  of  time — a  circumstance  that  is  well  calculated  to  enjoin 
caution  in  the  employment  of  ice. 

The  degree  to  which  the  prevalence  of  typhoid  fever  may  be  les- 
sened by  proper  drainage  and  a  suitable  water-supply  was  shown  first 
by  the  experiences  in  England,  to  which  were  soon  added  those  of 
France  and  Germany.  In  German  cities  that  formerly  suffered  seriously 
from  typhoid    fever — for    instance,   Munich — the    disease   has    at    the 

28 


434  TYPIIOW  FEVER. 

present  day  almost  ^vl1()lly  disappeared.  The  enormous  influence 
exerted  especially  by  a  good  water-supply  has  been  demonstrated  in 
France  by  the  experiences  with  regard  to  the  mortality  from  typhoid 
fever  in  the  army  and  in  the  civil  population.^  The  most  convincing 
example  in  Germany  is  furnished  again  by  Hamburg  (see  p.  45). 

FOOD  AS  A  SOURCE  OF  INFECTION. 
That,  in  addition  to  the  water,  most  careful  attention  should  be 
given  especially  to  fluids  employed  as  food  will  be  evident  from  previous 
statements.  The  first  place  in  this  connection  is  occupied  by  milk, 
which,  as  numerous  exact  investigations  have  shown,  may  be  a  source 
of  infection  from  intentional  or  accidental  addition  of  infected  water. 
Also,  the  articles  of  food  derived  from  it — butter,  cheese,  whey,  etc. — 
have  properly  received  great  attention  recently  from  the  prophylactic 
standpoint.  How  readily  still  other  articles  of  food,  especially  if  eaten  in 
an  uncooked  state,  such  as  fruit,  salad,  etc.,  may  be  infected  by  the  con- 
taminated hands  of  the  dispenser,  by  rinsing  and  sprinkling  with  M^ater 
containing  germs,  and  by  other  manipulations,  will  require  no  further 
elaboration.  Sanitary  ofiicers  should,  far  more  than  they  have  done  in 
the  past,  devote  attention  to  the  commercial  pursuits  involved  in  this 
connection,  such  as  dairies,  restaurants,  fruit-stores,  etc.  To  adopt 
prophylactic  measures  in  this  connection,  and  to  inquire  into  details, 
appear  to  me  far  more  important  than  the  still  quite  customary  fruitless 
examinations  of  soil  and  ground-water. 

PROPHYLAXIS  WITH  RELATION  TO  THE  INDIVIDUAL. 
In  this  connection  those  measures  should  be  considered  through 
which  the  dissemination  of  the  developed  disease  from  the  patients  to 
those  by  whom  they  are  surrounded,  and  from  these  to  more  remote 
persons,  is  to  be  prevented.  The  underlying  principle  of  the  measures 
in  question  may  be  expressed  in  two  sentences  : 

1.  The  only  infective  agent  consists  in  the  typhoid-bacilli  which  are 
reproduced  by  the  patient  and  are  extruded  especially  with  the  stools 
and  urine. 

2.  Residence  in  the  immediate  neighborhood  of  the  patient,  in  the 
same  house,  or  upon  the  same  floor  and  soil,  is,  in  itself,  absolutely 
innocuous,  even  for  predisposed  persons,  if  it  is  possible  to  protect 
them  from  the  ingestion  of  bacilli,  which  takes  place  by  far  the  most 
frequently  in  contaminated  food  and  beverages. 

It  therefore  follows  that  patients  are  to  be  so  taken  care  of  and 

1  See  Chanteniesse,  Abdotninaltyphus,  p.  737. 


PROrilYLAXIS.  435 

their  discharges  are  to  be  so  treated  that  tliey  shall  not  be  a  source  of 
injury  to  others.  The  patients  should,  so  far  as  practicable,  be  removed 
from  crowded  dwellings  and  from  surroundings  that  do  not  permit  of 
satisfactory  isolation  from  those  about  them,  and  they  should  be  sent  to 
the  hospitals.  Should  they  remain  in  private  dwellings,  a  number  of 
measures  that  would  be  matters  of  course  in  a  hospital  should  be  rigidly 
pursued,  but  with  appropriate  modifications. 

Treatment  at  Home. — In  treatment  at  home  one  of  the  essen- 
tial principles  consists  in  the  provision  of  nurses  and  assistants 
sufficiently  informed  with  regard  to  the  character  of  the  infection  and 
its  mode  of  prevention.  Those  who  do  not  assist  in  the  care  of  the 
patient  are  to  be  removed  from  his  vicinity,  or  at  most  must  be  per- 
mitted to  be  present  for  short  visits  only,  avoiding  direct  contact  with 
the  patient.  The  nurses  and  attendants  must  bear  scrupidously  in  mind 
the  fact  that  the  poison  contained  in  the  discharges  of  the  patient  may 
for  a  considerable  time  adhere  in  an  active  state  to  all  possible  articles, 
from  which  it  may  be  transmitted  directly  or  be  conveyed  for  great  dis- 
tances. It  is  not  less  important  for  them  to  know  that  patients  with 
mild  and  ambulatory  attacks,  as  well  as  healthy  persons,  may,  under 
certain  circumstances,  act  as  the  carriers  and  disseminators  of  the  virus. 

Of  the  more  important  details,  the  arrangement  of  the  sick- 
room may  especially  be  referred  to.  It  should  not  be  too  small,  should 
be  susceptible  of  ventilation,  and  situated  so  that  as  much  quiet  as  possi- 
ble can  be  secured.  Unnecessary  articles  should  be  removed,  and  this 
applies  especially  to  rough  woollen  articles,  counterpanes,  carpets,  and 
upholstered  furniture.  In  addition  to  the  sick-bed  proper,  a  second 
bed,  if  possible,  should  be  in  readiness  for  change. 

Disinfection  of  the  Stools. — The  dejections  of  the  patient, 
especially  the  stools,  are  best  received  in  porcelain  bed-pans  or  glass 
vessels  (which,  in  the  hospital,  should  be  reserved  for  this  particular 
purpose).  Before  being  thrown  into  the  water-closet,  thorough  disin- 
fection, preferably  with    milk  of  lime,  should  be  practised. 

This  is  to  be  preferred  to  all  other  disinfectants  on  account  of  its  cheap- 
ness, certainty,  ease  of  application,  and  convenience  to  the  attendants  and 
the  family.  In  detail,  care  should  be  taken  that  the  bottom  of  the  bed- 
pan be  covered  with  milk  of  lime  before  each  evacuation,  and  that  after 
the  bowels  have  moved,  the  stool  be  thoroughly  admixed  with  an  equal 
amount  of  milk  of  lime.  In  hospitals  provided  with  a  good  system  of  flushing 
and  drainage  the  dejections  thus  treated  may  be  thrown  at  once  into  the 
closet,  while  in  private  practice  it  is  advisable  to  permit  the  admixture  first 
to  stand  for  an  hour.  In  addition,  rigorous  supervision  and  disinfection  of 
the  closet  itself  are  necessary.  The  seat,  the  basin,  and  the  pipes  should  be 
treated  daily  with  milk  of  lime,  and  similar  care  should  be  devoted  to  the 


436  TYPHOID  FEVER. 

floor.  When,  instead  of  a  flu?ihing  system,  there  is  a  tuu-systeni  or  pit-svstem, 
disinfection  of  the  contents  of  the  pit  is  also  necessary — the  addition  daily  of 
from  100  to  150  grams  of  milk  of  lime  for  each  individual  being  considered 
sufficient.  That  thorough  rinsing  and  cleansing  of  bed-pans  and  glass  ves- 
sels should  be  effected  regularly,  best  with  a  solution  of  lysol,  niav  be  con- 
sidered almost  as  a  matter  of  course.  In  this  connection  attention  should  be 
given  especially  to  the  exterior  of  the  vessel  and  its  handle,  contact  with 
which  might  otherwise  readily  result  in  infection  of  the  hands  of  the  attend- 
ants. In  addition  to  milk  of  lime,  carbolic  acid,  and  lysol,  mercuric  chlorid 
is  also  applicable,  on  account  of  the  relatively  small  amount  of  mucus  and 
albumin  contained  in  the  typhoid  dejections. 

The  reliable  action  of  milk  of  lime  depends  upon  its  jiropcr  prepara- 
tion. It  should  be  employed  in  as  freshly  })repared  a  state  as  possible — 
at  any  rate  not  after  it  is  older  than  three  days.  It  is  best  to  pre])are 
the  necessary  amount  daily,  the  slaked  lime  being  mixed  Avith  from 
two  to  four  times  the  amount  of  water.  It  should  then  be  preserved  in 
closed  vessels.^ 

In  France  disinfection  with  copper  sulj^hate  is  much  employed,  especially 
upon  the  reconunendation  of  Vincent.'^  The  fecal  discharges  are  mixed  with 
an  adequate  amount  of  a  5  per  cent,  solution,  to  which,  besides,  1  per  cent, 
of  sulphuric  acid  is  added.  In  Germany  the  method  has  not,  to  my 
knowledge,  been  employed  upon  an  extensive  scale,  and  I  have  no  personal 
experience  with  it. 

Disinfection  of  the  Urine. — In  view  of  the  great  frequency 
with  which  typhoid-bacilli  are  found  in  the  urine  of  typhoid  patients, 
often  in  immense  numbers  (see  p.  34),  the  extreme  importance  of  care- 
ful disinfection  of  all  such  urine  will  be  apparent.  Gwyn  ^  has  made 
a  careful  experimental  study  with  reference  to  the  best  methods  by 
which  this  can  be  carried  out.  He  concludes  that  milk  of  lime  hardly 
deserves  the  name  of  a  disinfectant  in  this  connection.  Carbolic  acid  is 
of  use  only  in  large  amounts  and  strong  solutions  if  a  speedy  result  is 
■wished.  Formalin  is  an  excellent  disinfectant,  but  is  too  exj^ensive. 
Bichlorid  of  mercury,  chlorinated  lime,  and  liquid  chlorids  are  of  real 
value,  are  rapid  in  their  action,  and  are  efficient  in  comparatively  dilute 
solutions.  He  has  found  that  for  disinfection  within  five  to  fifteen 
minutes,  one  volume  of  urine  would  require  one-twentieth  to  one-tenth 
of  its  volume  of  1  :  1000  HgCla  solution. 

In  view  of  the  excellent  results  obtained  by  the  use  of  urotropin  in 
cases  of  typhoid  bacilluria,  Richardson  has  advised  the  routine  admin- 
istration of  this  drug  m  the  latter  periods  of  the  disease  as  a  preventive 

^  For  particulars  with  regard  to  disinfectants  and  methods  of  disinfection,  refer- 
ence maybe  made  to  an  article  by  E.  Pfuhl,  Zeit.  f.  Hyp.  u.  Infektionsk.,  Bd.  vi.,  vii., 
xii. 

2  Annates  de  VInstitut  Pasteur^  1895.  ■''  Johns  Hopkins  Hosp.  Rep.,  vol.  viii. 


PROPHYLAXIS.  437 

and  prophylactic  measure.  Probably  5-grain  doses  given  three  times 
a  day  are  sufficient  for  this  purpose.  It  should  be  mentioned,  how(;ver, 
that  several  cases  of  hemoglobinuria  following  the  continued  use  of  this 
drug  have  been  reported. 

The  disinfection  of  the  sputum  may  be  accomplished  by  the 
use  of  milk  of  lime  or  solutions  of  carbolic  acid  or  lysol. 

In  addition  to  the  secretions  and  excretions  of  the  patient,  the 
greatest  attention  should  be  given  to  many  other  things  that  come  in 
contact  with  him.  Thus,  wash- water  and  bathing- water  and 
also  remnants  of  food  from  the  typhoid  patient  should  not  be  thrown 
away  without  previous  disinfection  with  milk  of  lime.  Careful  attend- 
ants will  of  themselves  see  that  the  patient  is  provided  with  special 
plates,  glasses,  and  eating  utensils.  Especially  important  is  disinfec- 
tion of  the  bed-linen  and  the  body-linen,  and  any  other  articles 
of  clothing  used  by  the  patient,  as  well  as  his  napkins  and  hand- 
kerchiefs. 

In  order  to  avoid  unnecessary  throwing  about  and  repeated  manipulation, 
the  articles  in  question  are  best  kept  in  (not  water-tight)  sacks,  and  these  in 
turn  in  porcelain,  earthenware,  or  zinc  vessels  that  can  be  closed  and  are 
partly  filled  with  a  3  per  cent,  solution  of  carbolic  acid.  The  linen  thus  not 
completely  disinfected  is  first  subjected  to  sterilization  in  hot  steam  or  by 
boiling  in  soap-water,  with  addition  of  soda  or  petroleum  (Gartner),  before 
being  given  to  the  laundress,  and  only  then  submitted  to  the  remaining 
processes  of  washing. 

At  the  termination  of  the  disease  the  beds  are  to  be  thoroughly  dis- 
infected. Wooden  bedsteads  are  carefully  cleansed  with  a  5  per  cent, 
solution  of  carbolic  acid  or  lysol,  while  iron  bedsteads  are  treated  by 
steam  sterilization.  Mattresses,  blankets,  and  pillows  also  are  disin- 
fected by  steam.  When  steam-disinfection  is  not  available,  mattresses 
and  pillows  are  emptied,  and  both  covering  and  contents  are  disinfected 
by  boiling.  Valueless  articles  of  bedding — straw-sacks,  husk-piUows, 
etc. — had  better  be  burned  directly. 

The  bodies  of  those  dead  of  typhoid  fever  are  by  no  means 
so  dangerous  with  regard  to  the  dissemination  of  the  disease  as  was 
formerly  thought  under  the  influence  of  the  putrefactive  theor>\ 
Cleansing  and  covering  the  buccal,  nasal,  and  anal  orifices  with  gauze 
dipped  in  milk  of  lime  or  carbolic  solution  would  be  likely  to  suffice,  as 
a  rule.  If  especial  care  is  to  be  exercised,  particularly  in  the  matter  of 
distant  transportation,  the  body,  without  previous  washing,  should  be 
enveloped  in  cloths  saturated  with  carbolic  solution  or  milk  of  lime. 

Disinfection  of  the  Sick-room. — That  the  bedroom  should 
receive  most  careful  attention  during  and  after  the  attack  is  a  matter  of 


438  TYPHOID  FEVER. 

course.  After  it  has  been  vacated  by  the  convalescent  patient,  tlic  wall 
against  which  the  bed  stood  should  be  rubbed  down  with  bread,  or, 
should  its  covering  tolerate  moisture,  it  should  be  treated  with  a  5  per 
cent,  solution  of  carbolic  acid  and  soaj).  Furniture  used  by  the  patient, 
especially  the  bedstead  and  chairs,  and  the  floor,  should  be  disinfected 
in  the  latter  manner.  If  the  floor  is  not  painted,  it  will  be  better  to 
employ  milk  of  lime.  The  cracks  between  the  boards  should  receive 
particular  attention.  The  disinfection  of  rooms  not  occupied  by  the 
patient  and  kept  from  contact  with  his  dejections  is  unnecessary.  In 
private  practice,  especially  under  conditions  amid  which  the  methods 
of  cleansing  cannot  be  sufficiently  depended  upon,  it  is  advisable,  after 
emptying  the  room,  to  imdertake,  besides,  disinfection  with  the  vapor 
of  formalin. 

Especially  important  also  in  connection  with  prophylaxis  is  the 
maintenance  of  cleanliness  on  the  part  of  the  patient  him- 
self, of  his  skin  in  general,  particularly  about  the  mouth  and  the  anus, 
and  his  hands.  Particular  attention  should  be  directed  especially  to  the 
latter.  If  this  is  not  done,  the  patient  may  readily  convey  infectious 
material  to  various  utensils,  articles  of  food,  etc.,  and  thus  become  a 
source  of  danger  not  only  for  those  immediately  about  him,  but  for 
others  at  a  greater  distance.  The  attendants  must,  for  the  same 
reason,  devote  the  most  scrupulous  care  to  their  hands.  I  am  convinced 
that  not  a  few  cases  of  auto-infection  and  of  dissemination  are  attribu- 
table to  carelessness  in  this  connection. 

The  disinfection  of  the  hands  should  be  practised  according  to  the  rules 
observed  by  surgeons,  namely,  thorough  washing  and  brushing  with  soap 
and  water,  followed  by  "prolonged  immersion  in  mercuric-chlorid  solution, 
giving  proper  attention  to  the  nails  and  the  space  beneath  them.  In 
hospitals,  in  this  connection,  too  careful  supervision  of  the  nurses,  particu- 
larly ^those  of  short  experience,  cannot  be  exercised. 

Further,  physicians  and  nurses  in  attendance  upon  typhoid 
patients  should  be  provided  wdth  clothing  that  can  be  washed,  and  at 
the  end  of  their  service,  especially  before  going  to  their  meals,  they 
should  change  their  clothing.  In  hospitals  it  is  advisable,  in  case 
typhoid  patients  are  cared  for  in  the  same  ward  as  others,  to  provide 
but  one  nurse  for  their  care,  and  to  keep  others,  particularly  those  who 
are  concerned  in  bringing  the  food,  attending  to  the  cleansing  in  general, 
and  the  care  of  the  remainder,  as  strictly  as  possible  apart  from  the 
typhoid  patients.  When  typhoid  fever  occurs  in  boarding-schools, 
barracks,  jails,  and  institutions  in  general,  especially  those  containing 
young  persons  in  considerable  number,  immediate  isolation  of  the 
patients,  preferably  removal  from  the  house,  is  necessary.     Prophylactic 


PROPHYLAXIS.  439 

measures  would,  under  such  circumstances,  be  susceptible  of  application 
only  with  difficulty  and  uncertainty. 

Preventive  Inoculation. — In  addition  to  the  prophylactic  meas- 
ures above  discussed,  which  aim  especially  at  the  prevention  of  the 
further  spread  and  dissemination  of  the  virus,  there  has  lately  been 
introduced  a  measure  directed  toward  the  production  of  an  artificial 
immunity  in  the  individual. 

Following  the  work  of  Haifkine  in  vaccination  against  cholera, 
Wright,  of  Netley,  has  introduced  a  similar  method  of  vaccination 
against  typhoid.  The  material  used  is  a  bouillon-culture  of  Bacillus 
typhosus  of  high  virulence,  heated  until  all  organisms  are  dead.  The 
amount  inoculated  should  "  be  such  a  quantity  which,  if  injected  alive, 
would  be  fatal  to  a  350  gm,  guinea-pig."  The  inoculation  is  followed 
by  local  tenderness  and  congestion,  faintness,  possibly  nausea,  fever, 
and  restlessness.  Usually,  all  symptoms  have  disappeared  after  twenty- 
four  hours.  It  is  recommended  that  the  procedure  be  repeated  in  two 
weeks.  Following  the  injection  there  is  an  increase  in  the  bactericidal 
power  of  the  blood,  and  also  a  very  marked  increase  in  the  agglutinating 
power,  which  may  persist  for  at  least  two  years,  as  in  cases  reported  by 
Foulerton.  This  procedure  has  been  tried  on  a  large  scale  in  India, 
and  also  in  the  South  African  war.  Full  statistics  from  South  Africa 
are  not  yet  available,  but  out  of  1705  persons  inoculated  at  Ladysmith, 
only  2  per  cent,  were  attacked ;  whereas  of  10,529  not  inoculated,  14 
per  cent,  were  attacked,  and  of  those  inoculated  the  mortality  was  0.46 
per  cent. ;  of  those  not  inoculated  the  mortality  was  3  per  cent.  On 
the  whole,  the  experience  so  far  is  strongly  in  favor  of  inoculation. 
Such  a  method  is  naturally  most  applicable  in  the  case  of  persons 
going  into  a  district  where  the  disease  prevails,  or  in  the  case  of  armies 
or  other  large  bodies  of  persons  likely  to  be  attacked  by  an  epidemic  of 
typhoid  fever. 


V.    TREATMENT. 

OBSERVATIONS  ON  SPECIFIC  TREATMENT. 
AVe  are  yet  far  removed  from  a  specific  treatment  of  typhoid  fever,  i.  e., 
a  method  capabk'  of  destroying  its  exciting  causes,  the  tyj^hoid-baciUus, 
in  the  human  body  and  preventing  its  dissemination,  or  at  least  of  neu- 
tralizing or  attenuating  the  activity  of  its  toxins,  although  a  number 
of  recent  observations  stimulate  earnest  investigation  in  this  direction. 

Serum=treatment. — If  those  of  less  experience  believed  that  after 
Behring's  ingenious  discovery  of  the  action  of  the  diphtheria-serum  the 
production  and  the  application  of  a  "typhoid  serum  "  would  also  prove  con- 
venient and  inexpensive,  they  reasoned  without  sutHcient  foundation.  Con- 
clusions by  analogy  and  hopes  based  upon  them  are  especially  deceptive  in  the 
clinical  and  bacteriologic  field,  and  the  difficulty  and  the  peculiarity  of  the  con- 
ditions attending  typhoid  fever  especially  have  recently  been  again  demon- 
strated by  investigations  into  the  jdienomenon  of  agglutination  and  its  rela- 
tions to  immunity.  Valuable  preliniinaiy  investigations  on  the  subject  of 
serum-treatment  have  been  made  by  C'hantemesse  and  Widal,' and  especially 
bv  Stern,"  and  these  were  followed  by  Hammerschlag  ^  and  von  Jaksch,*  with 
investigations  into  the  therapeutic  activity  of  the  serum  of  convalescents 
from  typhoid  fever,  as  well  as  by  Beumer  and  Peiper,°Klemperer  and  Levy,*^ 
with  attempts  to  treat  typhoid  fever  with  injections  of  the  serum  of  immun- 
ized animals  (calf  or  dog). 

Although  these  observations  have  disclosed  a  limited  influence  of  the 
immune  serum  upon  experimental  typhoid  intoxication,  a  therapeutic  result 
with  reference  to  typhoid  fever  has  not  as  yet  been  made  out,  and  this  could 
scarcely  be  expected  to  be  otherwise,  in  view  of  the  entire  difference  of  the 
experimental  typhoid  infection  from  typhoid  fever  in  human  beings.  Hardly 
more  than  the  innocuousness  of  such  attempts  has  been  demonstrated.  The 
attempts  of  Rumpf  ^  to  treat  typhoid  fever  with  dead  cultures  of  Bacillus 
pyocyaneus,  based  upon  the  therapeutic  experiments  of  E.  Friinkel  with 
cultures  of  dead  typhoid-bacilli,  have  received  little  imitation,  and  their 
results  have  not  yet  been  confirmed." 

Even  at  an  early  period,  when  only  indefinite  conceptions  existed 
as  to  the  nature  of  the  typhoid  virus,  certain  methods  of  treatment 
were  employed  that  may  be  considered  among  the  specific.  Among  these 
may  be  included  the  early  attempts  to  cause  an  increased  number  of 

*  Ann.  de  Vlnstihit  Pasteur.,  1892. 

'^  Deutsch.  wed.  Woch.,  1892;  and  Zeif.f.  Hyg.  u.  Infektinmkrank.,  1894,  Bd.  xvi. 
s  Deutsch.  med.  TFocA.,  1893.  ■»  Pollak,  Zeit.f.  Heilk.,  1897,  reprint. 

5  Zeit.  f.  klin.  Med.,  1895,  Bd.  xxviii.;  and  Verhandl.  d.  XIII.  Cong.  f.  inn.  Med. 
8  Berlin,  klin.  Woch.,  1895.  ''  Deutsch.  med.   Woch.,  1893,  No.  41. 

8  Presser,  Zeit.f.  Heilk.,  Bd.  xvi. 
440 


TREATMENT.  441 

stools  by  means  of  purgatives,  and  thus  to  effect  elimination  of  the 
typhoid  virus  from  the  intestine.  Closely  related  to  tliese  were  certain 
methods  of  treatment  tliat,  going  a  step  further,  were  directed  toward 
neutralizing  abnormal  putrefactive  processes  in  the  intestine,  which  were 
considered  as  the  essential  feature.  These  represented  the  first  attempts 
at  intestinal  antisepsis.  In  this  category  belong,  undoubtedly,  the 
treatment  by  internal  administration  of  chlorin-water,  for- 
merly much  practised,  the  transitory  employment  of  carbolic  acid 
and  ben^oates,  and  the  iodin-potassium-iodid  treatment, 
warmly  recommended  by  Saner  and  Magonty,  and  still  defended  in  the 
year  1866  by  Willebrand.'  While  these  methods  possess  only  historic 
interest  at  the  present  day,  a  method  undoubtedly  allied  to  them, 
namely,  the  treatment  with  calomel,  still  has  ardent  advocates  among 
the  most  distinguished  living  physicians  (Liebermeister,  von  ZiemssenJ. 

Lesser,^  and  after  him  Schonlein,  Traube,  and  Wunderlich,  undoubtedly 
sought  to  obtain  with  the  remedy  not  simply  a  purgative  effect,  but  also  a 
specific,  locally  curative,  possibly  also  antitoxic,  action  upon  the  intestinal 
mucous  membrane.  It  was  believed  that  these  effects  were  most  manifest  at 
the  commencement  of  the  disease,  and  were  capable  of  inducing  an  abortive 
termination,  or  at  least  considerable  mitigation  of  the  intensity  of  the  disease. 

The  method  of  employment  still  recommended  by  the  advocates  of 
the  remedy  places  the  greatest  importance  upon  its  administration  at  the 
earliest  possible  period  of  the  disease,  at  all  events  before  the  end  of 
the  ninth  day.  Only  a  small  number  of  physicians  believe  that  the 
remedy  has  proved  useful  also  after  the  second  week  of  the  disease. 
Doses  of  0.5  gram  are  administered  at  intervals  of  one  or  two  hours, 
generally  three  or  four  in  the  twenty-four  hours,  at  the  beginning  of  the 
disease  (Liebermeister).  Liebermeister  believes  that  treatment  with  calo- 
mel induces  a  marked  mitigation  in  the  intensity  of  the  disease,  while 
von  Ziemssen,  going  somewhat  further,  attributes  to  the  remedy  an 
influence  in  diminishing  the  intensity  of  the  whole  infectious  condition, 
and  especially  of  the  local  intestinal  symptoms.  In  view  of  the  experi- 
ence of  these  two  trustworthy  writers  I  am  unwilling  to  advise  against 
the  employment  of  the  method  in  suitable  cases,  but  would  emphatically 
state,  with  Baumler  and  Weil,  that  I  have  been  unable  to  convince 
myself  of  its  abortive  and  abbreviating  effect.  What  I  have  observed 
was  an  increase  in  the  number  and  a  greenish  discoloration  of  the  stools, 
often  with  transitory  depression  of  the  temperature,  which,  however, 

'  Virchow's  Archiv,  Bd.  xxxiii. 

^  Die  Entzundung  und  Verschwarung  der  Schleimhaut  des  DartJikanales,  etc., 
Berlin,  1830. 


442  TYPHOID  FEVER. 

could  be  considered  as  a  result  of  the  diarrhea  itself,  and  not    as  a 
specific  effect  of  the  drug-. 

Undoubtedly,  too  little  consideration  has  been  given  to  the  fact  that  the 
abortive  course  of  cases  of  typhoid  fever  in  which  calomel  has  been  admin- 
istered at  the  outset  might  just  as  well  be  attributed  to  the  nature  of  the  case 
as  to  the  treatment  employed.  The  large  uund)er  of  cases  of  typhoid  fever 
pursuing  a  mild  and  short  course,  even  when  the  onset  has  been  severe,  as 
well  as  the  fact  that  this  number  may  at  times  be  greatly  increased  without 
apparent  cause,  should  be  kept  in  mind,  and  especially  it  should  not  be  for- 
gotten thaf  it  is  impossible  in  the  iirst  days  of  the  disease  to  foresee  the 
character  of  its  subsequent  course.  That,  however,  the  calomel  treatment, 
even  if  included  among  disinfectant  methods,  is.  like  all  others  of  its  class, 
without  sufheient  theoretic  foundation,  will  shortly  be  shown. 

The  earlier  endeavors  in  the  works  of  Eossbach '  and  Bouchard  ^ 
with  regard  to  systematic  intestinal  antisepsis  have  recently  been  taken 
up  anew  in  accordance  with  modern  views  and  methods.  They  aim  at 
the  introduction  into  the  intestine  of  bactericidal  remedies  in  amount 
and  form  capable  of  destroying  the  typhoid-bacilli  in  this  situation,  or 
at  least  of  inhibiting  their  development  and  dissemination.  Rossbach 
recommended  for  this  purpose  especially  the  employment  of  naphthalin  ; 
while  Bouchard  employed  a  series  of  remedies  successively — in  addition 
to  naphthalin,  a-naphthol  and  /3-naphthol,  iodoform,  salol,  calomel,  and 
combinations  of  several  of  these  remedies  or  in  combination  with 
others,  as,  for  instance,  naphthol  with  bismuth  salicylate.  The  methods 
have  hitherto  received  little  imitation  in  Germany,  while  Bouchard  in 
France  has  numerous,  in  part  enthusiastic,  disciples.  I  have  personally 
made  but  few  observations  with  the  method  of  Rossbach,  which  has  a 
frail  foundation.  I  have  not  ventured  to  follow  the  more  precise  direc- 
tions of  Bouchard.  His  method  requires  as  an  introductory  measure 
the  administration  of  15  grams  of  magnesium  sulphate  every  third  day, 
calomel  in  small  doses  for  general  antisepsis  for  four  days,  and,  finally, 
daily  doses  of  4  grams  of  naphthol  with  2  of  bismuth  salicylate. 

It  would  take  us  too  far  to  enter  fully  into  the  scientific  aspects  of  the 
method  of  treatment  in  question.  In  this  connection  I  would  refer  especially 
to  the  admirable  investigation  of  Stern, ^  which  led  experimentally,  prac- 
tically and  theoretically,  to  negative  results.  Also,  Fiirbringer,*  who  properly 
calls  attention  to  the  extraordinary  variations  in  the  number  of  bacteria 
present  in  the  stools  during  health,  was  unable  to  convince  himself  tbat  the 
introduction  of  antiseptic  substances  into  the  intestine  was  capable  of  effecting 
any  difference  greater  than  the  physiologic  one.     An  especially  severe  blow, 

*  Verhandl.  d.  Cong.  f.  inn.  Med.,  1884. 

'■'  Ler;ons  sur  lea  mdintoxic,  Paris,  1887  ;  and  Therapeutique  des  maladies  infect, 
antisepsis.  Paris.  1889. 

"  Volkmann's  Samjvhmg  klin.  Vortrdge,  N.  F.,  No.  138;  and  Zeif.  f.  Hyg.  u. 
hifckiionsk.,  1892,  Bd.  xii.  ^  Deutsch.  med.   Woch.,  1887. 


TREATMENT.  443 

finally,  was  inflicted  upon  the  doctrine  of  intestinal  antisepsis  by  the  recent 
observations  of  Fr.  Miiller,'  who  demonstrated  conclusively  its  impractica- 
bility in  healthy  and  diseased  human  beings  with  measures  availaltle  at 
present.  Even  though  it  were  assumed  that  there  existed  a  procedure  capa- 
ble of  injuring  the  pathogenic  micro-organisms  in  greater  degree  and  more 
permanently  than  their  hosts,  it  would  have  little  value  on  account  of  the 
relations  of  the  typhoid-bacillus  to  the  intestine  and  its  contents,  particularly 
in  cases  of  typhoid  fever.  It  is  known  that  even  at  a  time  when  the  disease 
does  not  generally  come  under  observation  for  treatment,  even  often  when 
the  clinician  has  as  yet  no  knowledge  of  its  existence,  the  bacilli  have 
already  passed  from  the  intestines  into  the  follicles,  the  mesenteric  glands, 
and  more  distant  organs,  especially  the  spleen,  where,  naturally,  they  are  no 
longer  accessible  to  antiseptic  remedies. 

It  is  therefore  justifiable  for  the  present  to  assume  a  doubtful 
attitude  toward  the  antiseptic  method,  and  even  one  of  skepticism  with 
regard  to  the  hope  that  it  may  in  future  prove  more  successful. 

For  the  present,  aud  probably  for  a  long  time,  the  successful  treat- 
ment of  typhoid  fever  will  have  to  be  pursued  in  some  other  direction. 
The  principal  factors  in  treatment  are,  therefore:  (1)  The  general 
appropriate  care  and  regulation  of  the  condition  of  the  patient,  espe- 
cially in  a  dietetic  direction ;  (2)  The  treatment  of  a  number  of  im- 
portant manifestations  and  symptom-groups,  of  complications  and  other 
dangerous  accidents,  and,  finally,  that  which  is  so  important,  supervision 
of  the  period  of  convalescence. 

NURSING  AND  DIET. 

Nursing. — The  typhoid  patient  should,  as  a  matter  of  course,  be 
kept  in  bed  throughout  the  entire  duration  of  the  febrile  state,  and 
beyond  this  into  the  period  of  convalescence.  Although  now  and  again 
ambulatory  cases  pursue  a  mild  course,  others,  however,  are  attended 
with  such  profoimd  manifestations  and  are  so  frequently  followed  by 
severe,  even  repeated,  relapses  and  unusually  protracted  convalescence, 
that  one  cannot  escape  the  impression  of  the  highly  injurious  influence 
of  an  ambulatory  course. 

Patients  whose  circumstances  offer  'no  assurance  of  adequate  care  at 
home  should  promptly  be  sent  to  the  hospital.  The  management 
of  a  case  in  a  private  house  requires  strict  regulation  of  external 
conditions.  Provision  for  the  utmost  physical  and  mental  repose  on 
the  part  of  the  patient,  and  order  and  discipline  in  the  sick-room,  are 
unconditional  requirements.  These  can  generally  be  attained  onlv 
through  well-trained  nurses.  When  the  care  of  the  patient  must  excep- 
tionally be  placed  in  the  hands  of  the  immediate  relatives,  only  a  few 

1  Verhandl.  d.  Co7iq.  f.  inn.  Med.,  1898. 


444  TYPHOID  FEVER. 

of  these  should  be  entrusted  with  these  duties,  and  these  should,  during 
the  period  of  their  acti\ity,  be  separated  from  the  other  occupants  of 
the  house  and  from  thos^e  employed  in  the  household,  particularly  in 
the  kitchen. 

The  sick-room  should  be  as  large  as  possible,  situated  in  a  quiet 
quarter,  and  easily  "ventilated.  The  best  room  in  the  house  is  just 
good  enough.  The  temperature  of  the  room  should  not  be  above  12° 
or  14°  C  During  favorable  periods  of  the  year  the  windows  should  be 
kept  open  day  and  night,  and  even  in  winter  a  thorough  airing  should 
be  practised  several  times  daily.  In  hospital  practice,  and  whenever 
possible  also  in  j)rivate  practice,  I  have  the  patients  during  the  summer 
lie  for  hours  in  the  open  air,  with  suitable  protection  from  sun  and  rain. 
Glaring  light,  and  also  especial  darkening  of  the  sick-room,  are  to  be 
avoided.  A'ery  unusual  articles,  decorations,  figures,  pictures,  and  the 
like,  about  which  the  phantasies  and  the  delirium  of  the  patient  readily 
revolve,  should  be  removed. 

The  sick-bed — making  allowance  as  far  as  possible  for  the  pre- 
vious habits  of  the  patient — should  iu  any  event  not  be  too  warm,  and 
should  be  readily  changed  and  rendered  clean.  Those  severely  ill 
should  be  promptly  placed  upon  a  water-bed.  The  sheets,  which  should 
be  changed  whenever  soiled  in  the  slightest  degree,  should  not  be  too 
coarse  in  texture,  and  never  wrinkled,  on  account  of  the  danger  of  bed- 
sores. For  the  same  reason  immediate  contact  of  waterproof  sheets 
with  the  body  should  be  avoided.  AVhile  at  the  commencement  of  the 
disease  quiet  recumbency  in  the  dorsal  decubitus  is  the  most  natural 
and  the  most  advantageous,  at  the  height  of  the  disease  and  toward  the 
end  of  the  febrile  stage  change  of  posture  should  be  encouraged,  and, 
especially  for  the  prevention  of  pulmonary  hypostasis,  frequent  alterna- 
tion of  the  dorsal  with  the  lateral  decubitus.  Evacuation  of  the  bowels 
and  the  bladder  should  take  place  exclusively  in  the  recumbent  posture 
even  into  the  period  of  convalescence.  Also,  when  the  bed  is  changed, 
the  patient  should  not  sit  up,  but  always  remain  in  the  horizontal 
posture — preferably  in  another  bed.  Many  a  case  of  fatal  collapse 
could  have  been  avoided  by  the  observance  of  these  precautions. 

That  in  maintaining  strict  cleanliness  of  the  body  attention  to 
the  dorsal,  sacral,  and  anal  regions  plays  a  special  rale  is  a  matter  of 
course.  Neglect  in  this  respect,  in  conjunction  with  defective  condi- 
tions of  the  bed,  leads  to  the  development  of  bed-sores,  which  are  but 
rarely  dependent  upon  the  nature  of  the  disease,  but  almost  always  upon 
deficiencies  in  nursing.  Especial  consideration  should  be  given  to  the 
mouth,   the  lips,   and   the  teeth   of  the   patient.      Frequent,    thorough 


TREATMENT.  445 

cleansing,  especially  after  the  ingestion  of  fo(j(l,  frequent  moistening  of 
the  lips,  and  the  frequent  proffering  of  small  quantities  of  fluid,  are 
indispensable.  A  well-nursed  patient  may  only  temporarily  exhibit 
dry  tongue  and  lips,  and  never  a  fuliginous  deposit.  In  women  great 
care  should  from  the  outset  be  given  to  the  hair,  which  should  be 
combed,  under  some  circumstances  cut  short,  or  preferably  be  worn 
in  a  net. 

Diet. — With  regard  to  few  points  in  connection  with  ty- 
phoid fever  is  there  at  the  present  day  such  satisfactory  agreement  as 
with  regard  to  the  dietetic  management,  of  which  the  principles  can  be 
considered  as  fully  established.  The  problem  presented  to  the  physi- 
cian and  demanding  tact  and  discrimination  consists  in  adapting  these 
principles  to  the  needs  of  the  individual  case.  In  general,  the  diffi- 
culties and  peculiarities  in  the  nourishment  of  typhoid  patients  are  to  be 
looked  for  in  two  directions  :  in  the  conditions  attending  the  infective 
or  the  febrile  state,  and  in  those  associated  with  the  local  changes 
induced  by  the  typhoid  process,  particularly  in  the  intestine. 

The  manifestations  of  the  toxic  action,  particularly  the  febrile  condi- 
tion, are  attended  with  profound  metabolic  disturbances,  among  which 
the  active  destruction  of  the  body-proteid  plays  an  important  role. 
It  is  the  most  important  problem  in  dietetic  treatment  to  shield  the 
proteids  from  this  destructive  process  as  far  as  possible  by  the  admin- 
istration of  carbohydrates  and  energy-sustaining  food.  It  must,  fur- 
thermore, be  taken  into  consideration  that  direct  replacement  of  the 
disintegrating  proteids  through  the  food  is  possible  only  in  a  wholly 
inadequate  manner,  on  account  of  the  febrile  derangement  in  diges- 
tive activity. 

Naturally,  the  body  nutrition  is  greatly  disturbed  in  many  other 
directions  also,  especially  with  regard  to  carbohydrates  and  fats.  It 
should  be  borne  in  mind  that,  in  addition  to  the  production  of  hydro- 
chloric acid  in  the  stomach,  the  functions  of  the  salivary  glands,  and 
probably  those  of  the  pancreas,  are  seriously  impaired,  and  also  the 
secretion  and  the  constitution  of  the  bile  are  altered,  conditions  that 
demand  careful  selection  and  preparation  of  the  food,  all  the  more  since 
peristalsis  and  absorption  appear  to  be  also  invariably  impaired. 

A  further  especially  important  peculiarity  of  t^^phoid  fever  with 
regard  to  the  dietetic  management  is  its  long  duration  as  compared 
with  other  infectious  diseases.  The  nutritive  disturbances  resulting 
from  the  morbid  process  as  a  result  attain  an  especially  high  grade. 
Their  augmentation  is  progressive  with  the  continuance  of  the  disease  ; 
and  this  naturally  increases  materially  the  difficulties  of  treatment,  and 


446  TYPHOID  FEVER. 

should  lead  the  physician  to  adjust  his  therapeutic  measures  systemati- 
ailly  from  the  beginning. 

Among  the  considerations  arising  out  of  the  local  alterations,  those 
dependent  upon  the  specific  intestinal  lesions  preponderate  over  all  others. 
The  physician  cannot  make  it  sufficiently  clear  for  himself  in  this  con- 
nection that  the  intestinal  symptoms  clinically  stand  in  no  direct  rela- 
tion to  the  distribution  and  the  severity  of  the  anatomic  lesions,  and 
that  every  case,  even  apparently  the  mildest,  may  be  attended  with 
extensive  and  profoimd  intestinal  ulceration. 

Fortunately,  it  is  entirely  possible  at  the  present  day  to  make  perfect 
allowance  for  the  local  conditions  without  returning  to  the  position, 
long  abandoned,  of  a  water-soup  and  hunger-diet.  Owing  to  the 
insight  of  English  physicians,  under  the  guidance  of  Graves,'  to  whose 
support  especially  ]\[urchison  ^  energetically  devoted  himself,  the  follow- 
ing principle  is  recognized  at  the  present  day  :  We  can  and  must 
fully  nourish  our  typhoid  patients  from  the  outset;  we  should  thereby 
endeavor  to  replace  the  disintegrating  proteids,  or  attempt  at  least  to 
limit  the  destruction,  by  means  of  energy -producing  substances,  carbo- 
hydrates, fats,  gelatinous  substances,  and,  finally,  also  alcohol. 

In  accordance  with  the  general  and  local  peculiarities  of  the  disease 
already  mentioned,  however,  throughout  the  entire  duration  of  the 
febrile  state,  and  for  a  certain  period  beyond  this  time,  all  articles  of 
food  should  be  given  only  in  a  fluid,  readily  digestible,  and  easily 
absorbable  form.  From  the  same  point  of  view,  care  should  be  taken 
that  nourishment  is  given  frequently,  in  severe  cases  by  day  and  by 
night,  always  in  small  amounts,  at  intervals  of  two  or  three  hours, 
and  that  also  somnolent  patients  should  be  induced  by  the  attendants 
to  take  food  regularly.  On  the  other  hand,  especially  in  private  ])rac- 
tice,  overfeeding  of  the  patient  should  be  cautioned  against,  and  it 
should  be  made  clear  from  the  outset  to  the  overzealous  friends  that  the 
physician  cannot  hope  during  the  febrile  stage  to  make  good  entirely 
the  loss,  but  that,  by  reason  of  the  rest  of  the  patient  in  bed  and  the 
otherwise  diminished  physical  and  psychic  expenditure  of  energy,  this 
is  of  little  significance,  and  that  the  loss  can  subsequently  be  readily 
regained. 

In  some  patients  anorexia,  even  actual  repugnance  for  the  food 
hitherto  administered,  makes  its  appearance  at  the  height  of  the  febrile 

1  CLiJiical  LerAures  on  the  Pmrtice  of  Medicine,  second  edition,  Dublin,  1848. 
This  work  contains  the  famous  statement  often  quoted  :  "  If  you  should  be  in  doubt 
as  to  an  epitaph  to  be  placed  upon  my  grave,  take  this  :    '  He  fed  fevers. 

2  The  Typhoid  Diseases,  German  translation  by  von  Ziilzer,  Berlin,  1867,  p.  234. 


TREATMENT.  447 

state,  in  a  larger  number  during  the  second  period  of  the  disease.  The 
experienced  physician  will  counteract  these  morbid  manifestations  not 
by  unnecessary  strictness,  but  by  appropriate  individual  selection  and 
variation,  A  febrile  typhoid  patient  is  not  a  subject  for  pedantic 
training.  Under  such  circumstances  the  wisest  will  yield,  and  this 
the  physician  should  be. 

Drinks. — Even  more  frequently  than  derangement  of  appetite, 
complaint  is  made  during  the  febrile  period  of  thirst,  and  in  somno- 
lent patients  an  eifort  will  be  made  on  the  part  of  the  friends  to  quench 
the  parched  condition  by  administration  of  fluids.  In  contrast  to  pre- 
vious views,  these  desires  may  be  unconditionally  acceded  to,  naturally 
with  a  consideration  of  individual  peculiarities.  Especially  cold  bever- 
ages, provided  they  were  well  borne  during  health,  and  even  the  addi- 
tion to  them  of  ice,  need  not  be  restricted.  The  best  drink  for  typhoid 
patients  is  ordinary,  good,  clear  water.  Also  certain  natural  mineral 
waters,  as  those  of  Selters,  Giesshiibel,  Bilin,  and  others,  may  be  per- 
mitted ;  while  artificial  waters  should  be  forbidden,  on  account  of  the 
excessive  amount  of  carbon  dioxid  they  contain. 

When  the  patients  express  an  especial  desire  for,  and  the  intestinal 
symptoms  do  not  contra-indicate  their  use,  fruit-juices,  such  as  syrup  of  rasp- 
berry, lemon-juice,  and  orange-juice,  may  also  be  added  to  the  water.  Some 
physicians  prescribe  almond-milk,  which,  however,  is  tolerated  by  only  a 
few  patients  for  any  length  of  time.  Still  better  borne  than  these  things  is 
addition  to  water  of  red  or  white  wine,  and  also  cognac  or  sherry.  For 
individuals  with  an  irritable  intestinal  canal,  weak  cold  tea  has  invariably 
answered  admirably  in  my  hands.  I  am  not  fond  of  prescribing  albumin- 
water  or  gum- water,  or  of  bread-infusion  or  mucilaginous  drinks.  By 
means  of  these  the  appetite  of  the  patient  is  spoiled  for  actual  nourishment, 
and  in  addition  the  keeping  of  the  mouth  clean  is  thereby  rendered  unneces- 
sarily difficult. 

Among  actual  articles  of  food,  the  first  place  should  be  given  to 
milk.  Theoretically,  this  appears  undoubtedly  to  be  the  most  rational 
form  of  nourishment  for  febrile  patients,  inasmuch  as  it  represents  the 
ideal  combination  of  proteid,  fats,  carbohydrates,  and  salts  in  a  liquid 
form.  Especially  the  fats,  which  are  so  important  for  febrile  patients, 
and  utilized  with  so  much  difficulty,  are  most  finely  divided  in  milk, 
and  are  in  the  form  of  an  extremely  permanent  emulsion,  and  are 
thereby  rendered  as  easily  assimilable  as  possible.  Although  some 
physicians,  accordingly,  advocate  an  almost  exclusively  milk-diet  in 
cases  of  typhoid  fever,  it  mav  be  objected  that  not  many  patients  care 
for  it  for  any  length  of  time,  and  a  still  larger  number  do  not  bear  it. 

The  patients  then  complain  of  pressure  in  the  epigastrium,  a  sense  of 
fulness' or  of  abdominal  tension,  and  of  pyrosis  and  eructation,  and  the  stools 


448  TYPHOID  FEVER. 

contain  slightly  altered,  coarse  coagulu  of  milk  in  undesirable  amount. 
Most  fivqueiuly  the  adniiuistratiou  of  milk  it:  ])reveiited  by  the  fact  that  it 
gives  rise  to  the  formation  in  the  stomach  of  fchrile  patients  of  firm,  lumpy 
coagula,  whicli  are  with  ditHculty  tiigested  by  reason  of  the  diminution  in 
hydrochloric  acid  present.  This  can  at  times  be  avoided  by  administering 
only  boiled  milk,  the  coagula  of  which  are  softer  and  smaller.  Dilution 
with  ordinary  water,  jnineral  water,  or  lime-water,  also,  may  be  of  service 
in  this  connection.  It  is  particularly  advantageous  often  to  add  mucilagi- 
nous substances  to  the  milk,  such  as  oatmeal,  tapioca,  arrow-root,  and  similar 
articles.  Some  patients  tolerate  the  addition  of  salt  or  cognac  to  the  milk  to 
improve  the  taste.  Others  are  grateful  for  permission  to  take  the  milk  in 
the  form  of  kephyr.  Under  such  circumstances,  it  is  true,  the  considerable 
amount  of  carbon  dioxid  present  should  be  borne  in  mind.  At  times  the 
administration  of  buttermilk  serves  a  useful  purpose.  Although  it  must  be 
considered  as  less  valuable  on  account  of  the  absence  of  fat,  it  is  easily 
digestible  for  the  reason  that  in  consequence  of  the  mechanical  influences  to 
which  it  is  su])jected  in  the  making  of  butter,  the  casein  it  contains  is  in  an 
especially  fine  state  of  division.  For  patients  who  bear  milk  very  well,  the 
addition  of  cream  may  be  permitted.  To  some  patients  the  administration 
of  milk  in  a  frozen  state  is  most  agreeable.  Such  ice-cream  is  prepared  by 
freezing,  in  a  shallow  vessel  or  by  means  of  a  cold-mixture,  milk  which  has 
been  condensed  in  a  vacuum,  and  to  which  has  been  added  a  small  amount 
of  sugar,  and  for  those  who  care  for  it,  cinnamon,  vanilla,  or  the  like. 

A  not  less  important  role  is  played  by  the  administration  of  carbo- 
hydrates in  the  form  of  mucilaginous  soups,  which  may  be  given 
alone  or  together  with  other  nutrient  or  stimulating  articles,  especially 
with  bouillon  or  proteids. 

In  order  to  render  tolerable  for  some  time  the  mucilaginous  soups 

which  are  so  necessary,  the  physician  must  have  a  wide  range  of  formulse. 
Among  all  the  substances  to  be  taken  into  consideration  in  this  connection, 
oatmeal  has  the  greatest  nutritive  value,  on  account  of  the  relatively  large 
amount  of  fat  and  proteid  it  contains.  Unfortunately,  it  often  early  excites 
the  distaste  of  the  patient.  Under  such  circumstances  it  should  be  alternated 
with  rice,  wheat,  green  corn,  maize,  tapioca,  palm  sago,  and  the  like.  I 
would  further  recommend  especially  the  addition  to  soups  of  aleuronat  flour, 
which,  as  is  w^ell  known,  contains  80  per  cent,  of  proteids,  is  soluble  in  water 
and  is  not  coagulated  by  heating,  and  which  is  admii-aldy  borne  by  almost 
all  patients.  In  the  case  of  children  and  young  adults,  success  is  often  had 
with  artificial  food  (Nestle' s,  Kufecke's,  and  others).  Some  patients  like 
the  addition  of  white  or  red  wine,  instead  of  bouillon,  to  the  broth.  In  the 
later  stages  of  the  disease — as  the  stage  of  steep  curves  and  that  of  defer- 
vescence— certain  other  additions  may  be  made,  such  as  legumins  or  Harten- 
stein's  leguminose. 

Among  the  nutrient  and  stimulant  articles,  meat-broth  prepared 
at  home  is  by  far  the  most  to  be  recommended,  and  in  preparing  this 
it  should  be  noted  that  the  meat  of  full-grown  animals  (cow  and  ox) 
contains  a  larger  amount  of  extractives,  and  that  of  veal  and  young 
fowl  a  smaller  amount. 

In  the  care  of  sensitive  patients  the  presence  of  fat  in  bouillon  should  be 


TREATMENT.  449 

avoided  as  fully  as  possible,  and  this  may  be  sufficiently  effected  by  permit- 
ting it  to  cool,  and,  before  heating  it  again,  skimming  off  the  coagulated 
layer  of  fat  on  the  surface.  It  is  still  more  advisal)le  in  such  cases  to  pre- 
pare the  meat-broth  by  adding  hot  water  or  mucilage  to  a  definite  amount  of 
"bottle  bouillon."  The  best  mode  of  preparation,  especially  if  the  presence 
of  gelatin  also  be  desired  at  the  same  time,  consists  in  l)oiling  over  the 
water-bath,  for  from  two  to  four  hours,  equal  parts  of  veal  or  beef,  without 
the  addition  of  water.  The  juice,  expressed  tlirougli  a  cloth,  which  at  times 
is  quite  clear,  may  be  used  in  the  manner  descriljed,  as  an  addition  to  milk 
or  taken  cold  in  the  form  of  jelly. 

A  large  number  of  artificial  products  have  been  placed  upon  the  market 
for  the  preparation  and  for  increasing  the  concentration  of  bouillon.  A  number 
of  these  are  free  from  objection  ;  however,  some  are  quite  expensive,  and 
at  any  rate  they  offer  no  advantage  over  the  bouillon  prepared  at  home. 
Of  the  most  approved  of  these  there  may  be  mentioned  Liel)ig's  extract  of 
beef.  Brand's  essence  of  beef,  and  Valentine's  meat-juice.  Closely  related 
to  them  are  the  so-called  meat-peptones,  which  actually  possess  but  little 
nutritive  value,  and  only  the  influence  of  the  extractives  and  the  salts 
contained  are  to  be  taken  into  consideration. 

In  addition  to  carbohydrates,  the  g'elatinous  substances,  which 
in  Germany  have  been  again  restored  to  favor  by  Senator,  may  be 
mentioned  as  an   admirable  means  of  shielding  the  body-proteids. 

The  jelly  is  best  prepared  from  calves'  feet ;  but  under  some  circum- 
stances it  may  also  be  made  from  good  varieties  of  commercial  gelatin.  It 
may  be  administered  in  the  form  of  an  addition  to  soup,  in  the  form  of  the 
"  bottle  bouillon "  already  mentioned,  or,  what  is  especially  refreshing  to 
many  patients,  in  the  form  of  wine-jelly  or  fruit-jelly.  Fastidious  patients 
will  be  grateful  if  the  gelatinous  addition  to  soup  be  made  in  the  form  of 
crab-jelly  or  oyster-jelly. 

Some  reserve  should  be  exercised  in  the  administration  of  actual 
proteid  nourishment  in  cases  of  typhoid  fever  during  the  febrile 
stage.  Solid  meat-food  of  any  kind  should  be  strictly  forbidden.  Also, 
QggS  should  be  given  only  with  caution,  in  especial  form,  and  should 
never  be  urged  upon  the  patient.  They  are  generally  permitted  to  be 
taken  raw,  and  only  the  yolk  stirred  in  soups.  In  addition,  the  yolk 
may  be  given  beaten  up  with  bouillon  or  wine,  particularly  port 
or  sherry.  Eggs  admixed  with  milk  are  much  more  difficult  of 
digestion. 

In  Osier's  clinic  at  the  Johns  Hopkins  Hospital,  egg-albumin  is 
very  freely  given  to  typhoid  patients,  usually  in  the  form  of  albumin- 
water.  In  preparing  this  the  albumin  is  thoroughly  shaken  with  ice 
and  a  small  amount  of  water,  and  is  then  strained,  and  flavored  with. 
lemon,  sherry,  or  brandy. 

Von  Ziemssen  especially  recommends  meat-albumin  in  the  form  of 
recently  expressed  beef=Juice,  which  has  been  incorporated  into  the  German 
Pharmacopeia.     This  contains  6  per  cent,  of  dry  proteid  (Voit  and  Bauer), 

29 


450  TYPHOID  FEVER. 

» 

and  apparently  is  quite  easily  digestible.  It  is  well  borne  by  many  patients 
as  au  addition  to  soup,  anil  liy  others  alone  in  a  liquid  or  frozen  state. 
For  sensitive  i)atients  the  addition  of  peppermint  is  a  good  corrective. 
When  the  patients  object  to  the  turbid,  bloody  apjiearance,  the  fluid  may  be 
administered  in  a  green  glass. 

Of  artificial  proteid  foods,  a  clear,  thick  juice,  made  intensely  red  by 
admixture  with  hemoglobin,  and  designated  puro,  has  recently  been  recom- 
mended, which,  according,  to  the  statement  of  the  manufacturer,  contains  20 
per  cent,  of  proteid,  but  the  value  of  which  still  requires  clinical  investiga- 
tion. Occasionally,  the  meat-preparation  of  Leube-Rosenthal  may  be  valu- 
able. Of  the  meat-]ieptones,  of  which  Kemmerich's  antl  Denayer's  may  be 
mentioned,  1  rarely  make  use.  The  physician  is,  of  late,  frequently  impor- 
tuned bv  the  friends  of  the  patient,  who  often  have  liecome  fanatics  on  the 
question  of  nourishment,  to  use  still  other  of  the  modern  proteid  prepara- 
tions. Kutrose,  somatose,  and  eucasin  are  those  most  commonly  mentioned. 
Somatose  is  a  readily  soluble  mixture  of  proteids  prepared  from  meat,  and 
almost  free  from  peptone.  Isutrose  and  eucasin  are  similar  preparations 
made  from  milk.  These  powdered,  readily  soluble  substances  may,  by 
reason  of  their  almost  total  tastelessness,  be  highly  serviceable  when  added 
in  amounts  of  a  teaspoonful  to  soups  and  beverages,  particularly  to  patients 
who  have  a  repugnance  to  the  use  of  eggs. 

In  spite  of  all  theoretic  objections,  alcoholic  beverages  are 
still  indispensable  to  the  practitioner  in  the  treatment  of  typhoid  fever, 
as  well  as  in  the  treatment  of  acute  febrile  diseases  in  general.  It 
■would  be  superfluous  at  the  present  day  to  discuss  former  objections 
■with  regard  to  the  influence  of  alcohol  in  increasing  the  fever.  Von 
Zierasseu,  Jiirgensen,  and  Liebermeister  have  permanently  disposed  of 
this  prejudice.  Although  the  theoretic  explanation  is  difficult,  prac- 
tically the  stimulating  influence  of  alcohol  upon  the  circulation  and 
respiration  is  established  beyond  doubt.  In  addition,  it  is  useful  for 
conserving  ■waste  and  generating  energy.  I  should  not  be  -willing  to 
treat  typhoid  patients  at  all  in  certain  stages  and  conditions  -without 
alcoholics.  The  employment  of  alcohol  naturally  requires  strict  dis- 
crimination in  every  case.  In  children  it  is  to  be  avoided  altogether,  or 
to  be  employed  only  temporarily  as  a  last  resort.  In  severe  cases  in 
adults  I  permit  from  the  outset  small  quantities  of  spirituous  drinks  to 
be  taken  regularly,  undiluted  or  diluted,  keeping  in  mind  the  consti- 
tution and  previous  habits  of  the  patient,  gradually  increasing  the 
amount  with  the  rise  of  the  fever.  Care  should  be  taken,  apart  from 
alcoholics,  not  to  give  large  doses  at  the  beginning,  in  order  not  to 
jeopardize  the  possibility  of  effective  increase  in  times  of  necessity. 

It  is  best  to  employ  wine  and  strong  spirits.  Exceptionally,  beer  may  be 
used,  and  then  preferably  those  varieties  that  are  rich  in  hops,  are  well  fer- 
mented, and  rich  in  alcohol,  and  they  should  be  given  only  in  small  amounts. 
Among  wines,  the  red  Bordeaux,  Burgundy,  and  old  Rhine  red  wines 
(Assraannshausen  and  the  like)  are  in  general  to  be  preferred  in  view  of 


TREATMENT.  451 

the  intestinal  alterations  ;  also,  white  Rhine  wines  of  some  age  are  usually- 
well  borne.  Some  patients  bear  southern  wines — sherry,  port,  Madeira, 
and  Tokay — also  some  Italian  and  Greek  varieties.  They  may  Ijo  adminis- 
tered undiluted  or  mixed  with  natural  Selters  water  or  cold  tea.  Undi- 
luted, these  wines,  which  contain  from  12  to  17  per  cent,  of  alcohol,  are 
employed  in  the  presence  of  progressive  weakness  and  conditions  of  collapse  ; 
and  in  their  stead,  or  alternating  with  them,  also  champagne,  care  being 
taken  in  this  connection  to  avoid  the  dishonestly  prepared,  less  valuable 
varieties  so  common  at  the  present  day.  While  ordinary  white  and  red 
wines  contain  from  7  to  8  per  cent,  of  alcohol,  good  brands  of  champagne 
contain  from  10  to  10.5  per  cent.  If  there  be  any  reason  to  employ  the 
stronger  alcoholics,  cognac,  rum,  and  arac  may  be  administered  in  tea  or 
black  coffee.  A  convenient  mode  of  administering  cognac,  by  means  of 
which  the  dose  can  be  well  regulated,  is  in  the  form  of  the  well-known 
Stokes  mixture.  This  is  especially  available  also  for  persons  who  do  not 
tolerate  alcohol  well ;  in  addition,  the  contained  eggs  appear  to  be  easily 
digestible.  The  formula  employed  at  my  clinic  consists  of  strong  cognac 
50,  yolk  of  egg  1,  syrup  of  cinnamon  20,  distilled  water,  sufficient  to  make 
150. 

DIET  DURING  THE  PERIOD  OF  DEFERVESCENCE  AND  THE 
STAGE  OF  CONVALESCENCE. 

It  has  already  been  seen  that  in  many  patients  the  appetite  begins  to 
return  during  the  stage  of  steep  curves,  and  almost  always  and  in  still 
greater  degree  after  defervescence.  The  desires  of  the  patient  should  be 
restrained  at  this  time  on  account  of  the  still  precarious  state  of  the  intes- 
tinal canal.  On  the  other  hand,  one  should  not  be  altogether  too  timid, 
as,  if  the  restriction  in  diet  be  too  long  continued,  convalescence  and 
the  resumption  of  functional  activity  may  be  unduly  deferred.  Even 
during  the  stage  of  steep  curves,  especially  if  meteorism  be  not  present 
or  antecedent  symptoms  of  peritonitic  irritation  or  hemorrhage  does  not 
admonish  especial  caution,  I  permit  the  addition  of  soup  to  be  taken 
in  considerable  amount,  or  the  carbohydrate  articles  of  food  to  be  eaten, 
even  in  the  form  of  a  thin  pap.  Instead  of  eggs,  sweetbread  or  brain 
passed  through  a  fine  sieve  may  be  added  to  soups.  These  articles 
must  suffice,  with  as  much  variation  as  possible,  until  the  end  of  the 
first  afebrile  week. 

From  the  sixth  or  the  seventh  afebrile  day  I  permit  the 
first  solid  food,  beginning  with  some  zwieback  or  cakes,  especially 
pastry  prepared  from  aleuronat,  soaked  in  milk,  tea,  or  cocoa.  Then  a 
soft-boiled  e^g  may  be  permitted,  and  finely  scraped  raw  fillet  or  salmon 
or  a  mixture  of  the  two. 

The  meat  is  scraped  with  a  silver  spoon  upon  a  porcelain  dish,  and  for 
the  first  days  additionally  passed  through  a  fine  sieve. 

If  all  these  are  well  borne,  roast  young  fowl,   squab,  chicken,  or 


452  TYPHOID  FEVER. 

partridg^e  may  be  given,  at  first  in  the  form  of  puree  added  to  soup ; 
then,  finely  divided,  without  fat  sauce.  At  the  same  time  or  soon  after- 
ward, mashed  potatoes  or  well-stirred  rice,  and,  with  the  meat,  some 
crust  of  roll  or  toast,  may  also  be  permitted.  These  articles  may  soon 
be  followed  by  light  fish,  especially  trout,  boiled  in  salt  water.  After 
this,  scraped,  slightly  overdone  fillet  may  be  given,  and  all  these  are 
f  )ll(t\ved  at  the  end  of  the  second  or  at  the  beginning  of  the  third 
afebrile  week  by  broiled  lean,  tender  pieces  of  meat,  veal  or  mutton 
cutlet,  and  fillet  of  beefsteak,  young  game,  hare,  or  deer. 

In  the  course  of  the  third  week  resort  may  be  had  to  light  vegeta- 
bles, asparagus-tips,  spinach,  puree  of  green  peas,  carrots,  artichokes, 
and  the  like.  During  the  second  and  third  weeks  of  convales- 
cence it  is  necessary  to  administer  food  at  least  five  times  daily  ;  some- 
thing should  be  proffered  the  patient  even  during  the  night,  if  he  is 
awake,  such  as  milk,  cakes,  and  the  like.  In  addition,  all  sorts  of 
trifles  should  be  given  the  patient  during  this  period  between  the  prin- 
cipal meals — at  first,  wine  or  meat  jelly  ;  if  reduced,  caviar  or  oysters  ; 
the  patient  will  be  grateful  also  for  apple-sauce  or  other  forms  of  stewed 
fruit  that  are  not  too  sweet.  Uncooked  fruits,  however,  should  be 
withheld  for  a  long  time. 

The  dietetic  regulations  previously  mentioned  will  naturally  serve  only 
as  a  ireneral  guide  for  the  solicitous  physician,  from  which  he  will  arrange  a 
dietary  in  accordance  with  the  patient  and  the  character  and  the  stage  of  the 
disease.  While  we  must  require  strict  obedience  from  patients  and  assistants 
with  reeard  to  the  diet,  their  instructions  should  be  given  in  a  clear  and 
well-defined  manner.  During  the  critical  periods  of  the  disease  it  is  wise, 
in  order  that  no  difference  of  opinion  may  arise  between  the  patient  and  the 
nurse  and  the  family,  that  the  daily  instructions  with  regard  to  diet  be  given 
in  detail  in  writing. 

The  mode  of  treatment  described  in  the  foregoing  is  often  designated 
"  expectant,"  but  without  propriety.  It  has  been  seen  that  the  attitude 
of  the  physician  is  anything  but  expectant ;  but  that,  on  the  contrary, 
he  is  fully  and  most  responsibly  occupied  with  carrying  out  the  treat- 
ment. One  must  go  even  further  and  say  that  for  the  mild,  moderately 
severe,  and  even  for  a  nurnber  of  severe,  uncomplicated  cases,  particularly 
in  previously  healthy  individuals,  the  dietetic  treatment  and  careful 
supervision  otherwise  render  superfluous  every  other  measure.  Fur- 
ther therapeutic  intervention  will  be  necessary  only  if  the  course 
of  the  attack  be  severe  or  unusual,  or  in  the  presence  of  alarming 
conditions  with  reference  to  certain  systems  or  organs,  whether  repre- 
senting peculiar  localizations  of  the  typhoid  process  or  actual  complica- 
tions.     Particular  attention  has  always  been  given  to  the  fever  in  this 


TREATMENT.  453 

connection,  and  tlie  last  thirty  years  especially  have  witnessed  the 
assumption  of  first  place,  practically  and  theoretically,  of  the  methods 
of  treatment  comprehended  under  the  designation  antipyretic. 

THE  SaCALLED  ANTIPYRETIC  METHODS  OF  TREATMENT. 

i^arlier  and  Present-day  Methods. — Even  at  the  present  day 
there  is  still  abundant  reason  for  giving  especial  attention  to  antipyretic 
methods  of  treatment,  but  the  present  standpoint  afforded  by  the  recent 
results  of  etiologic  investigation  is  quite  different  from  the  former  one. 
The  symptom-complex  designated  fever  may  be  considered  in  the  main 
as  an  expression  of  the  action  of  the  typhoid  toxin  upon  the  tissues  and 
metabolism.  The  sole  rational  method  of  treatment  for  fever  would, 
accordingly,  consist  in  neutralizing  the  vital  manifestations  of  the 
bacilli,  and  particularly  the  toxic  effects  to  which  they  give  rise.  As 
is  well  known,  we  are  still  far  from  this  goal. 

Although  for  a  long  time  one  of  the  most  conspicuous  symptoms  of 
the  fever,  the  elevation  of  body-temperature  was  looked  upon  as  the 
most  deleterious,  and  therefore  the  most  worthy  of  attack,  and  by  some 
is  still  so  considered  at  the  present  day,  this  view  is  no  longer  tenable 
in  the  light  of  current  conceptions  regarding  the  nature  and  mechanism 
of  the  infectious  processes.  Our  present  treatment  is  directed,  on  the 
whole,  toward  rendering  the  effects  of  the  toxins,  which,  as  has  been 
noted,  cannot  be  entirely  prevented,  so  far  as  possible,  innocuous  for  the 
patient,  and  toward  sustaining  his  powers  of  resistance  until  the  infec- 
tious process  has  spontaneously  exhausted  itself.  Although  at  present 
much  less  importance  is  attached  to  direct  control  of  the  elevation  of 
temperature  than  formerly  was  the  case,  we  do  not  go  so  far  as  to  ignore 
this  entirely,  nor  do  we  consider  it  as  the  vis  medicatrix  naturce,  and 
therefore  not  to  be  interfered  with,  as,  owing  to  the  revival  of  old  theo- 
ries, is  believed  at  the  present  day.  On  the  contrary,  it  must  be  admitted 
that  unusually  high  temperature,  especially  if  maintained  for  a  long 
time  and  at  a  uniform  level,  may  in  itself  be  attended  with  serious  evils, 
viz.,  acceleration  of  respiration  and  pulse,  and  probably  also  increase 
in  proteid  disintegration  and  in  the  oxidation-processes  in  general. 
However,  in  cases  of  typhoid  fever  this  is  practically  to  be  taken  into 
consideration  in  far  less  degree  than  in  connection  with  some  other 
infectious  diseases  ;  because  in  cases  of  otherwise  severe  tv^phoid  fever, 
even  during  the  fastigium,  the  elevation  of  the  body-temperature  is  in 
general  confined  within  moderate  limits. 

Although  we  are  thus  unable  to  share  the  view  of  those  who 
judge  of  the  febrile  process  principally  from  the   state  of  the  ther- 


454  TYPHOID  FEVER. 

mometcr,  and  as  a  routine  procedure  aim  at  reduction  of  the  tempera- 
ture, Ave  still  believe,  nevertheless,  that  measures  diraeted  to  the  relief 
of  the  symptom-complex  as  a  whole,  and  thereby  to  the  relief  of  a 
number  of  disturbances  whose  marked  development  and  prolonged 
duration  may  become  a  source  of  danger  to  the  patient,  are  often  indi- 
cated and  often  constitute  an  important  part  of  the  treatment.  The 
disturbances  present  are  especially  those  resulting  from  the  action  of 
the  toxins  upon  the  central  nervous  system,  and  consist  in  the  conse- 
quent states  of  sopor,  coma,  delirium,  and  profound  involvement  of 
the  most  vital  cerebral  centers,  especially  those  of  respiration  and  circu- 
lation, and  upon  which  also  certain  disorders  of  the  digestive  organs, 
of  the  urinary  secretions,  and  of  the  functions  of  the  muscles,  are 
intimately  dependent.  That  by  correcting  the  fimctional  disturbances 
of  the  systems  and  organs  in  question  the  body  may  be  rendered  more 
resistant  to  external  morbid  influences — that  is,  to  the  development  of 
complications — and  that  at  the  same  time,  apart  from  the  immediate 
indications,  provision  may  be  made  for  the  future  is  a  further  object 
of  the  antipyretic  method  of  treatment. 

From  the  foregoing  it  follows  that  the  limits  of  the  antipyretic 
methods  of  treatment  are  at  the  present  day  in  many  directions  more 
extensive,  and  in  others  less  so  :  more  extensive  in  so  far  as  we  do  not 
attempt  to  attack  a  single  symptom,  but  an  entire  group  of  severe  con- 
sequences of  the  intoxication,  and  this  method  of  treatment  is  therefore 
thought  to  be  indicated  not  only  when  the  temperature  reaches  a  high 
level,  but  also  when,  as  so  often  happens,  the  intoxication  is  most  mani- 
fest with  a  low  body-temperature,  or  when  it  is  scarcely  elevated  at  all ; 
less  extensive  in  so  far  as  the  indication  for  antipyretic  treatment  is  no 
longer  looked  for  in  a  perfunctory  manner  in  ever}'  elevation  of  body- 
temperature  above  a  certain  degree,  but  principally  in  profound  dis- 
turbances of  the  central  nervous  system,  the  circulation,  and  the 
respiration,  in  consequence  of  which  the  larger  number  of  mild  and 
moderately  severe  cases  are  not  subjected  to  antipyretic  treatment. 

With  these  qualifications  the  antipyretic  methods  of  treatment  may 
now  be  discussed.  Hydrotherapy  may  be  looked  upon  as  its  most 
efficient  and  most  important  form,  while  the  employment  of  the  so- 
called  antipyretic  medicaments  are  much  less  used  and  esteemed. 

HYDROTHERAPY. 

Historic. — As  with  the  main  principles  of  dietetic  management,  we  are 
mainly  indebted  to  English  physicians  for  the  principles  of  hydrotherapy  also. 
It  was  first  employed  systematically  in  typhoid  diseases  toward  the  end  of 


TREATMENT.  455 

the  eighteenth  century  hy  the  Liverpool  physician,  James  Currie.'  He 
used  water,  principally  in  the  form  of  cold  douches,  at  from  5"^  to  10°  C, 
giving  them  generally  twice  daily,  beginning  at  an  early  period  of  the  dis- 
ease. He  was  soon  imitated  by  many  physicians  in  all  countries,  so  that  in 
the  third  edition  of  his  book  he  was  able  to  re[)ort  numerous  confirmations 
of  his  success  in  his  mode  of  procedure.  Undoubtedly,  Currie's  statistics 
apply  both  to  typhus  and  to  typhoid  fever,  which  at  that  time  could  not  b<^ 
thoroughly  differentiated. 

From  Currie's  douches,  which,  were  for  a  long  time  adhered  to  in  France 
as  almost  the  sole  method  by  the  most  distinguished  physicians  TRecambier, 
Trousseau,  Chomel,  and  Guenneau  de  Mussy),  there  developed  grad- 
ually the  method  of  treatment  with  cold  baths.  In  combination  with 
the  douches,  and  also  variously  modified  in  other  respects,  they  were  em- 
ployed extensively  in  Germany  in  the  first  two  decades  of  the  nineteenth 
century,  and  soon  became  so  highly  esteemed  that  one  of  the  most  enthu- 
siastic advocates  of  hydrotherapy,  E.  Horn,'  designated  it  as  the  only 
useful  method  in  the  treatment  of  typhoid  fever.  Nevertheless,  the 
procedure  was  not  generally  adopted.  Although  still  practised  by  some 
(von  Gietl,  Niemeyer,  Traube,  Armitage,  Graves),  it  gradually  became  dis- 
placed by  certain  medicinal  methods — antipyretic  and  antiputrefactive.  In 
Germany  it  was  revived  by  E.  Brand,'  of  Stettin.  To  him  belongs  the 
credit  of  having  developed  and  applied  the  procedure  methodically,  and 
thereby  of  having  given  the  stimulus  for  a  new,  permanent,  and  successful 
movement.  As  the  leaders  in  this  who  based  their  clinical  experiments  and 
observations  upon  the  prevailing  conception  of  the  typhoid  process  and  of 
the  role  played  by  elevation  of  temperature  in  fever,  Jiirgensen,*  Lieber- 
meister  and  Hagenbach,*  Ziemssen  and  Immermann  ^  should  be  men- 
tioned. In  France,  Glenard  flSTS),  of  Lyons,  introduced  the  method  into 
practice,  and  after  him  especially  Fereol  and  Reynau  ;  then  Renoy,  Tripier 
and  Bouveret,''  and  others.  The  method  soon  became  popular  also  in  the 
remaining  countries  of  the  continent  of  Europe,  and  also  in  England  and 
America. 

Various  Methods  of  Employment. — The  methods  of  apply- 
ing vrater  are  extremely  diverse.  Often  some  modes  have  been  de- 
fended w^ith  great  persistency  as  alone  useful.      In  addition  to  the  early 

1  Medical  Reports  on  the  Effects  of  Water  as  a  Remedy  for  Fever ^  etc.,  London, 
1797.  German  translation  by  Michaelis,  Leipsic,  1801.  Compare  the  historic  descrip- 
tion of  the  development  of  the  method  in  England  and  France  in  Murchison's  book, 
from  which  most  subsequent  writers  have  taken  their  data. 

2  Erfahrungen  uber  die  Heilung  des  ansteckenden  Nerven-  und  Lazarethfiebers^ 
Berlin,  1814. 

^  Die  Hydrotherapie  des  Typhus,  Stettin,  1861.  Zur  Hydrotherapie  des  Typhus, 
Stettin,  1862.     Die  Heilung  des  Typhus,  Berlin,  1868. 

*  Klin.  Studien  iiber  die  Behandlung  des  Abdominaltyphus  mittelst  des  kalten 
Wassers,  Leipsic,  1866. 

*  Beobachtungen  und  Versuche  iiber  die  Anivendung  des  kalten  Wassers  bei  fieber- 
haften  Krankheiten,  Leipsic,  1868. 

^  Die  Kaltwasserbehandlung  des  Typhusabdo7ninalis,  Leipsic,  1870. 

'  La  fievre  typholde  traiiee  par  les  bains  froids,  Paris,  1890.  This  careful  article 
is  based  upon  a  large  number  of  cases,  and  constitutes  the  best  description  of  the  devel- 
opment and  the  present  status  of  the  question  in  France. 


456  TYPHOID  FEVER. 

douches  of  Ciirrie,  at  the  present  day  spongings,  frictions  with  cold 
water,  or,  as  is  almost  universally  customary  iu  France  and  in  England, 
with  vinegar-water,  are  practised ;  further,  Avet  packs  of  varying  tem- 
perature and  duration,  partial  refrigeration  by  means  of  allusions, 
the  use  of  water-bags  filled  with  cold  water,  ice,  or  even  cold  mixtures, 
half-baths  with  frictions  or  douches  (as  were  recommended  by  Brand 
in  his  first  publication),  and,  finally,  fiill  baths  of  most  varied  kind. 

Treatment  by  Baths. — Full  baths  are  at  the  present  day  by 
far  most  commonly  used ;  while  the  other  methods  are  mostly  employed 
as  auxiliary  measures  or  as  partial  substitutes  M'hen  baths  cannot  be 
used  on  account  of  individual  or  extraneous  reasons.  At  first,  under  the 
profound  influence  of  the  labors  of  Brand  and  his  successors,  and  in  con- 
sequence of  overestimation  of  the  significance  of  febrile  elevation  of  tem- 
perature, cold  baths  were  preferably  given  at  temperatures  as  low  as  from 
6°  to  10°  C,  and  these  were  warmly  advocated  at  Wiesbaden  '  as  late  as 
1882.  In  order,  so  far  as  possible,  to  avoid  the  supposedly  deleterious 
overheating  of  the  blood  and  the  tissues,  a  bath  thus  became  necessary 
whenever  the  temperature  reached  a  certain  level — generally  above  39° 
or  39.5°  C. — so  that  the  patient  not  rarely  received  from  ten  to  fifteen 
cold  baths  in  the  course  of  twenty-four  hours.  It  was  entirely  over- 
looked in  this  connection  that  rest  and  equanimity  are  not  less  impor- 
tant therapeutic  factors,  which  cannot  be  disregarded  with  impunity. 

ISIost  physicians  have  at  the  present  day  returned  to  less  radical 
methods.  Personally,  I  still  employ  very  cold  baths  only  exceptionally. 
In  general  I  content  myself  with  lukewarm  baths,  and  with  especial 
preference  for  those  that  are  gradually,  and  then  usually  but  moderately, 
cooled,  such  as  von  Ziemssen  has  introduced  into  practice.  If  one  does 
not  yet  know  the  patients  with  regard  to  their  susceptibility  to  hydro- 
therapeutic  measures,  they  are  first  placed  in  a  full  bath  at  a  temperature 
of  from  31°  to  34°  C.  Perhaps  the  first,  but  generally  the  second, 
bath  may  be  cooled  to  27°  or  25°  C.  by  the  gradual  addition  of  cold 
water.  The  use  of  water  at  a  temperature  below  22°  C".  is  rarely  indicated. 
The  baths  are  at  first  of  from  ten  to  fifteen  minutes'  duration,  and  sub- 
sequently are  extended  up  to  twenty  and  even  thirty  minutes,  the  latter 
especially  when  the  shorter  duration  yields  only  slight  and  not  persistent 
effects  upon  the  central  nervous  system,  the  pulse,  and  the  respiration.  In 
cases  in  robust  young  individuals,  if  stupor  and  confusion  are  marked, 
cold  spongings  or  cold  douches  to  the  head  and  back  are  associated  with 
the  bath.  These  may  be  practised  several  times  in  the  course  of  the 
same  bath,  or  but  once,  shortly  before  its  termination,  in  accordance 

1  Cong.  f.  inn.  Med. 


TREATMENT.  457 

with  the  character  of  the  case.  In  the  cases  also  in  which  the  douche 
is  not  employed,  it  is  advantageous  to  cover  the  head  of  the  patient  with 
an  ice-bag  or  with  a  cold  cloth.  It  is,  however,  unnecessary  and 
superfluous  to  have  the  patient,  while  in  the  bath,  drink  cold  water 
abundantly,  in  order,  as  it  were,  to  cool  additionally  the  interior  of  the 
body. 

Certain  details  should  be  strictly  followed  in  the  practical  application  of 
the  bath.  The  patient  should  never  get  into  or  out  of  the  bath  unassisted, 
even  if  the  tub  be  placed  at  the  side  of  the  bed.  He  must  always  be 
Jifted  and  carried  by  the  attendants.  The  bath-water  should  cover  the 
chest,  almost  to  the  neck,  and  the  well-supported  patient  should  remain 
quiet.  On  the  other  hand,  he  is  gently  rubbed  persistently  and  the  water  is 
constantly  kept  in  movement.  Debilitated  individuals  may  take  small 
quantities  of  alcohol — tea  with  cognac,  port  wine,  or,  with  advantage,  Stokes's 
mixture — before  and  during  the  course  of  the  bath.  After  the  bath  all 
patients  should  receive  such  stimulants.  At  the  conclusion  of  the  bath  the 
patient  should  be  dried,  always  in  the  recumbent  posture,  upon  an  alternate 
bed,  and  delicate  patients  should  be  dried  beneath  a  woollen  blanket.  They 
should  then  be  kept  in  bed,  suitably  but  not  too  heavily  covered,  and  the 
utmost  quiet  about  them  should  be  maintained.  It  is  agreeable  and  advan- 
tageous to  some  patients,  as  von  Ziemssen  especially  advised,  not  to  be  dried 
at  once,  but  to  be  permitted  to  lie  quietly  and  to  sleep,  and  to  have  their 
clothing  changed  only  subsequently  on  awaking. 

In  private  practice  the  tub  is  kept  in  the  room  constantly,  at  the  side 
of  the  bed  of  the  patient,  while  in  the  hospital  it  is  generally  portable,  or 
often  the  patient,  in  bed  is  moved  into  the  bath-room.  The  practice  of  per- 
mitting the  water  to  stand  for  days  in  the  tub,  and  of  using  it  for  several 
days  in  succession  after  warming  it  by  the  addition  of  amounts  of  hot  water, 
is  a  practice  that  should  be  strongly  condemned.  This  would  make  it 
impossible  to  secure  the  necessary  cleanliness  on  the  part  of  the  patient,  and 
would  certainly  give  rise  not  rarely  to  infectious  diseases  of  the  skin — 
furunculosis  and  phlegmon.  In  addition,  the  danger  to  the  attendants  from 
such  infected  water  is  by  no  means  to  be  underestimated. 

Indications  and  Counterindications. — The  repetition  of  the 
bath  is  governed  less  by  the  range  of  the  body-temperature  than  by  the 
symptoms  referable  to  the  central  nervous  system,  the  pulse,  and  the 
respiration.  Most  physicians  at  the  present  day  endeavor  to  avoid 
extreme  reductions  in  temperature  by  means  of  the  bath.  From  the 
use  of  the  kind  described,  the  simple  lukewarm  baths,  or  the  Ziemssen 
gradually  cooled  bath,  the  reduction  generally  does  not  exceed  one  or 
two  degrees.  In  general  this  may  be  considered  as  quite  sufficient.  Even 
in  severe  cases  and  at  the  height  of  the  disease,  from  two  to  at  most  four 
baths  in  the  course  of  twenty-four  hours  will  generally  be  sufficient. 
The  lukewarm  bath  (from  25°  to  30°  C),  of  long  duration — up  to 
twenty-four  hours — has  been  warmly  recommended  by  Ries.  His 
views  have  been  accepted  by  Affanassief  and  Manassein,  as  well  as 


458  TYPHOID  FEVER. 

by  Unverricht.  Recently,  they  have  been  highly  praised  also  by  Eich- 
horst,  and  they  are  therefore  worthy  of  further  trial,  on  account  of  the 
wide  experience  and  the  reliability  of  this  writer.  Cases  of  severe 
onset,  with  symptoms  of  intense  persistent  intoxication,  should  from 
the  outset  be  subjected  to  the  bath-treatment,  which  should  be  governed 
strictly  by  the  indications  present  in  the  individual  case,  and  be  conjoined 
with  the  auxiliary  hydriatic  measures  previously  mentioned.  Under 
such  circumstances  the  bath-treatment  cannot  be  replaced  by  any  other 
measure,  and  its  omission  or  inadequate  employment  is  to  be  considered 
a  serious  mistake.  The  conditions  are  different  with  regard  to  the  mild 
and  moderately  severe  cases.  These  may  not  require  the  bath-treat- 
ment ;  diet,  rest,  and  the  systematic  regulation  of  the  remaining  condi- 
tions are  here  generally  quite  sufficient.  Should  exacerbations  occur  or 
intercurrent  severe  symptoms  arise,  baths  should  be  given  also  in  these 
cases  at  varying  intervals,  in  accordance  with  the  existing  circum- 
stances. 

In  all  cases  of  typhoid  fever,  further,  I  have  given  daily  one,  pos- 
sibly two,  cool  or  tepid  spongings,  which  are  refreshing  and  exert  a 
favorable  influence  upon  the  nervous  system.  In  moderate  and  severe 
cases  an  ice-bag  is  kept  constantly  applied  to  the  head  throughout  the 
febrile  period.  When  the  pulse-frequency  is  high,  it  is  well  also  to 
apply  an  ice-bag  over  the  heart.  Marked  intestinal  symptoms,  espe- 
cially meteorism,  demand  the  application  of  affusions  to  the  abdomen. 
If  bronchitis  be  severe,  moist  packs  applied  to  the  thorax  and  changed 
not  too  frequently  are  of  great  advantage. 

Of  the  remaining  hydrotherapeutic  measures,  to  which,  however,  the 
principal  advocates  of  such  measures  attach  slight  antipyretic  value,  I 
make  little  use ;  among  these  cold  packs  are  most  to  be  recom- 
mended. For  many  patients  these  are,  however,  troublesome,  and 
especially  exhausting  if,  as  is  recommended  in  order  to  insure  their 
efficacy,  they  are  repeated  every  hour  or  two,  and  if,  in  addition,  cold 
water  is  used.  I  dispense  entirely  with  the  application  of  cold  secured 
by  filling  the  water-cushions  Avith  cold  water,  ice,  or  even  cold  mixtures. 

Wliereas  caution  has  been  several  times  advised  in  the  employment 
of  vigorous  bathing-procedures,  especially  very  cold  and  frequently 
repeated  full  baths,  there  are  also  certain  absolute  and  relative  contra- 
indications to  even  milder  methods  of  procedure.  Every  form  of  bathing- 
treatment  is  strictly  forbidden  on  the  appearance  of  the  first  sign  of 
intestinal  hemorrhage,  as  well  as  on  the  appearance  of  even  the  slightest 
degree  of  peritonitic  irritation.  The  method  is  also  dangerous  in 
patients   with  weakness  of  the  heart,   especially   that   resulting  from 


TREATMENT.  459 

recent  myocarditis,  endocarditis,  or  pericarditis.  Also,  persons  with 
arteriosclerosis  or  incompletely  compensated  valvular  lesions  of  some 
standing  are  to  be  excluded  from  the  bath-treatment.  Pleuritic  eff'u- 
sions  of  considerable  amount  likewise  constitute  a  rigid  contra-indication, 
while  in  the  case  of  dry  pleurisy  and  pneumonia  this  method  is  contra- 
indicated  only  if  they  are  associated  with  weakness  of  the  heart.  Phlebitis 
also  constitutes  a  contra-indication  to  the  bath-treatment.  Diffuse  bron- 
chitis or  a  tendency  to  hypostasis  of  the  lungs  is  considered  in  my  clinic 
as  a  special  indication  for  the  bath-treatment.  In  cases  presenting 
severe  laryngeal  lesions  it  is  best  to  omit  the  bath-treatment.  Sup- 
purative inflammation  of  the  middle  ear,  with  perforation  of  the 
tympanic  membrane,  demands  great  care  to  prevent  the  entrance  of 
bath-water.  Much  caution  should  be  exercised  in  bathing  persons  who 
have  previously  been  ill,  especially  those  having  tuberculosis  or  bron- 
chiectasis with  a  tendency  to  hemorrhages  or  in  the  presence  of  marked 
emphysema. 

Old  age  also  may  constitute  a  contra-indication.  The  baths  are 
generally  not  well  borne  by  persons  above  the  age  of  fifty  years  ;  even 
of  those  persons  between  forty  and  fifty,  only  a  small  number  are 
favorable  subjects  for  this  treatment.  In  children  the  bath-treatment  is 
in  general  less  commonly  indicated,  both  on  account  of  the  usually  mild 
course  of  the  disease,  and  particularly  by  reason  of  the  greater  powers  of 
resistance  on  the  part  of  the  nervous  system  and  of  the  heart.  Children 
generally  pass  quietly  and  safely  through  an  attack  of  typhoid  fever 
without  any  active  treatment.  Should  hydrotherapeutic  measures  be 
indicated  by  special  conditions,  particularly  those  involving  the  nervous 
system,  such  as  restlessness,  somnolence,  or  coma,  lukewarm  baths,  with 
gradual  reduction  in  temperature,  and  douches,  in  accordance  with  the 
conditions  present,  will  almost  solely  be  appropriate.  Children  bear 
very  cold  baths  even  worse  than  adults. 

Certain  physiologic  states  of  the  body,  especially  the  puerperium, 
lactation,  and  menstruation,  do  not  constitute  absolute  contra-indi- 
cations.  With  regard  to  the  constitution,  chlorotic  and,  in  general, 
anemic,  debilitated  individuals  are  usually  to  be  spared  forcible 
measures.  Great  care  should  be  observed  in  the  case  of  obese  persons. 
They  commonly  bear  hydriatic  treatment  poorly.  Even  in  youthful 
persons  of  this  character,  particularly  in  "  blooming,  thriving "  young 
women,  unfortunate  experiences  are  not  rarely  encountered.  Such 
individuals  exhibit  a  tendency  to  weakness  of  the  heart,  which  becomes 
manifest  unexpectedly  and  in  an  alarming  degree,  especially  after 
frequent  cool  baths.     The  great  tendency  to  cardiac  weakness  often 


460  TYPHOID  FEVER. 

renders  the  baths  dangerous  also  for  alcoholics.  That  there  are  also 
previously  apparently  healthy  persons  who,  when  attacked  with  typhoid 
fever,  do  not  bear  the  baths  well  and  become  markedly  languid  and 
exhausted  in  consequence,  is  a  noteworthy  fact.  Of  the  several  varieties 
of  typhoid  fever,  only  the  rare  hemorrhagic  variety  really  demands  care 
with  rcfjard  to  hvdriatic  measures. 

ANTIPYRETIC    MEDICAMENTS. 

The  Value  and  Action  of  Antipyretic  Drugs. — Antipyretic 
drugs,  which,  even  at  the  height  of  the  bath-treatment,  were  considered 
by  the  majority  of  physicians  as  less  important  than  the  latter,  to-day, 
in  spite  of  their  almost  daily  increasing  number  and  often  warm 
endorsement,  play  a  minor  role.  The  nature  of  their  influence  upon 
the  elevation  of  temperature  is  still  in  dispute,  and  apparently  is  not 
the  same  for  the  different  remedies.^  Evidently,  none  of  them  exerts  a 
specific  influence  upon  the  morbid  process,  and  therefore  the  antipyretic 
effect  is  not  at  all  comparable  to  that  of  quinin  in  the  presence  of 
malaria.  A  favorable  influence  upon  the  central  nervous  system,  the 
pulse,  and  the  respiration,  which  is  considered  as  an  especially  impor- 
tant result  of  the  bath-treatment,  is  scarcely  demonstrable  following  the 
use  of  the  antipyretic  drugs,  with  a  few  exceptions.  The  majority,  on 
the  contrary,  in  full  doses,  give  rise  to  markedly  depressing  or  directly 
injurious  secondary  effects. 

To  the  simple  reduction  in  temperature,  which  all  these  agents 
usually  bring  about  in  marked  degree,  the  earlier  significance  is  by  no 
means  attached  at  the  present  day,  as  has  been  seen.  The  custom,  still 
far  too  common,  of  administering  antipyretics  in  a  routine  manner 
whenever  the  temperature  reaches  a  certain  level,  and  thus,  of  course, 
frequently,  is  to  be  condemned.  The  extreme  efforts  to  maintain  the 
temperature  at  a  low  level  for  a  considerable  time,  or  constantly 
"  afebrile,"  as  it  is  designated,  by  the  administration  of  salicylic  acid, 
kairin,  thallin,  and  the  like,  are  actually  dangerous,  and,  fortunately, 
have  been  almost  entirely  abandoned. 

Personally,  I  make  incomparably  far  less  use  of  antipyretic  drugs 
than  of  baths.  From  year  to  year  1  have  gradually  given  up  the 
former  more  and  more,  and  the  large  majority  of  my  patients  leave  the 
hospital  without  having  received  any  of  these  drugs.  I  can  make  this 
statement  with  a  clear  conscience,  as  my  experiences  during  the  last  ten 
years,  compared  with  those  during  the  period  in  Avhich  I  prescribed 

'  Compare  the  discussion  upon  antipyresis,  Cong.  f.  inn.  Med.,  1885  ;  and  Internat. 
Cong.  z.  Kopenhagen. 


TREATMENT.  461 

these  remedies  more  freely,  are  not  any  less  favorable  than  the  latter. 
If  at  the  present  time  I  still  occasionally  administer  an  antipyretic 
drug,  this  is  done  preferably  in  the  so-called  hyperpyretic  cases,  and 
then  especially  when  the  baths  cannot,  for  extraneous  or  individual 
reasons,  be  employed.  I  restrict  myself,  however,  in  this  connection  to 
a  few  remedies,  of  which  I  know  that  with  very  slight  or  no  injurious 
secondary  effects,  they  exert,  in  addition  to  the  reduction  in  temperature, 
also  some  influence  upon  the  typhoid  state. 

I  do  not  use  salicylic  acid  or  sodium  salicylate.  Although  they  reduce 
the  body-temperature  markedly  and  certainly,  thoy  have  neither  au  abbre- 
viating nor  any  other  favorable  influence  upon  the  course  of  the  disease. 
They  may,  in  fact,  not  rarely  be  actually  dangerous,  in  so  far  as  thoy  may 
cause  collapse  in  persons  presenting  not  entirely  normal  cardiac  conditions. 
In  Germany,  accordingly,  the  use  of  the  preparations  of  salicylic  acid  has 
apparently  been  abandoned  by  most  physicians ;  while  in  France,  under  the 
influence  of  Guenneau  de  Mussy,  Jaccoud,  and  Vulpian,  these  preparations 
are  still  employed. 

Kairin  also  has  properly  been  almost  abandoned.  Its  administration  is 
likewise  almost  unexceptionally  followed  by  marked  depression  of  the  body- 
temperature,  but  generally  with  most  unpleasant,  often  actually  alarming, 
secondary  manifestations :  cyanosis  with  cold  sweats,  cardiac  weakness,  and 
occasionally  profound  disturbance  of  breathing.  The  action  of  thallin  appears 
to  resemble  that  of  kairin,  but  is  attended  with  less  serious  secondary  mani- 
festations. In  the  opinion  of  competent  authority,  however,  the  entire  effect 
is  less  marked  and  less  persistent. 

I  would  admonish  also  against  the  use  of  antifebrin.  Although  it  is 
markedly  antipyretic  (three  or  four  times  more  so  than  antipyrin),  its  admin- 
istration may  be  followed  by  quite  unanticipated  and  dangerous  secondary 
manifestations,  even  when  it  is  given  only  in  small  doses.  Undoubtedly, 
even  death  may  be  attributable  to  its  administration.  The  secondary  mani- 
festations in  question  consist  in  chilliness,  cyanosis,  and  especially  irregu- 
larity and  feebleness  of  the  action  of  the  heart.  Certain  older  remedies, 
particularly  veratrin  and  digitalis,  play  no  role  whatever  as  antipyretics  at 
the  present  day. 

Together  with  most  physicians,^  I  employ  almost  only  quinin,  anti- 
pyrin, and  phenacetin.  Contrary  to  a  number  of  others,  of  these 
I  still  prefer  quinin.^  With  a  proper  administration — this  must 
naturally  be  learned — it  has  almost  as  certain  an  effect  as  the  other 
two,  and  generally  a  more  permanent  effect ;  while  such  secondarj^  dis- 

^  See,  for  instance,  von  Ziemssen,  Behandlung  des  Typhus ;  Penzoldt  u.  Stintzing, 
Hand.  d.  Therap.,  Ed.  i. 

^  See  Liebermeister,  "  Ueber  die  antipyretische  Wirkung  des  Chinin,"  Deutsch. 
Arch.  f.  Tdin.  Med.,  1867,  Bd.  iii.  "  Antipyretische  Heilmethoden, "  Ziemssen's 
Hand.  d.  Therap.,  Bd.  i.  "Typhus  abdominalis, "  Ziemssen's  Hand.  d.  spec.  Path, 
u.  Therap..^  Bd.  i.  The  well-known  investigations  of  Liebermeister  are  still  at  the 
present  day  sutBcient  justification  for  the  employment  of  the  remedy.  Even  previously, 
Broca  (1840),  in  France,  and  W.  Vdgt  (1859)  and  Wachsmuth  (1863)  had  made 
investigations  concerning  quinin,  without,  however,  having  cleared  up  the  situation. 


4&2  TYPHOID  FEVER. 

turbances  as  may  be  present  are  far  less  disagreeable  and  almost  free 
from  danger.  The  ringing  in  the  ears,  so  distressing  to  other  patients, 
makes  little  impression  upon  the  typhoid  patient,  on  account  of  his 
state  of  stupor.  Vomiting  is  by  no  means  so  frequent  as  it  is  often 
said  to  be,  and,  what  is  most  important,  the  remedy  is  the  least  danger- 
ous of  all  these  antijiyretic  drugs,  even  when  the  heart  is  in  an  unstable 
condition. 

The  dose  for  au  adult  is  from  1  to  1.5  grains.  Rarely,  I  give  as  much  as 
2  grams,  and  scarcely  ever  more.  The  administration  should  take  place,  as 
Liebermeister  recommends,  not  at  the  height  of  the  temperature-elevation, 
but  some  time  earlier,  in  order  to  counteract  this  so  f:;r  as  possible.  As  the 
action  of  quinin  generally  becomes  distinctly  apparent  only  in  the  course  of 
two  or  three  hours,  the  drug  should  be  administered  at  least  this  period  in 
advance  of  the  expected  maximum  temperature.  The  decline  in  body-tem- 
perature generally  reaches  the  lowest  level,  on  the  average,  from  eight  to 
twelve  hours  after  the  ingestion  of  the  quinin.  If  the  temperature  then 
begins  to  rise  again,  it  does  not,  in  many  cases,  reach  the  previous  level, 
even  in  the  course  of  an  additional  twenty-four  hours.  It  is  noteworthy  that 
the  remedy  should  be  administered  at  once  in  full  dose,  or  in  a  few  smaller 
doses  at  intervals  of  not  longer  than  from  one-quarter  to  one-half  an  hour. 
Smaller  doses  extended  over  a  longer  period  of  time  are  inefficient  for  anti- 
pyretic purposes  (Liebermeister).  The  remedy  is  best  administered  internally 
in  starch-capsules,  followed  by  one  or  two  tablespoonfuls  of  a  mixture  of 
hydrochloric  acid.  Should  administration  by  the  stomach  be  followed  by 
vomiting,   the  remedy  may  readily  be  given  by  enema. 

The  antipyretic  effect  of  antipyrin  is  more  rapid  and  more  marked. 
In  my  experience,  however,  it  causes  vomiting  more  frequently,  and, 
what  is  most  serious,  heart-weakness  not  rarely  occurs,  unless  great 
care  is  observed  in  its  administration.  First  prepared  by  Knorr  and 
introduced  into  therapeutics  by  Filehne,  it  is  at  the  present  time  proba- 
bly the  most  commonly  employed  antipyretic.  It  is  best  administered, 
as  Liebermeister  first  suggested  for  quinin,  and  then  also  recommended 
for  antipyrin,  during  the  afebi'ile  period,  in  order  that  its  effects  may 
be  utilized  in  preventing  the  daily  exacerbation.  Like  quinin,  its  use 
is  followed,  not  only  by  a  reduction  in  the  body=temperaturc,  but  not 
rarely  also  by  improvement  in  the  mental  state  and  by  a  certain  feeling 
of  well-being.     The  dose  is  from  2  to  5  grams. 

When  first  administered,  it  is  advisable  not  to  give  the  entire  dose  at 
once,  but  in  two  equal  parts,  with  an  interval  of  an  hour  between  them. 
In  patients  in  whom  there  is  any  misgiving  as  to  the  condition  of  the  heart, 
it  is  well  to  administer  at  first  only  from  1  to  1.5  grams,  and  thereafter 
hourly  a  dose  of  from  0.75  to  1  gram.  The  remedy,  if  badly  borne  by 
the  stomach,  may  be  administered  by  enema,  and,  by  reason  of  its  ready 
solubility,  even  subcutaneously. 

Phenacetin,  w^hich  has  a  similar  effect  to  antipyrin,  and  is 
employed  in  half  the  dose,  is  advisable  in  some  cases.     It  is  better 


TREATMENT.  463 

borne  by  some  patients  than  is  antipyrin.  In  its  administration  also 
the  condition  of  the  pulse  should  receive  careful  attention. 

With  lactophenin  (dose,  from  0.5  to  1  gram),  which  has  been 
recommended  by  von  Jaksch/  and  which  has  been  credited  by  this 
observer  and  also  by  Immermann  with  exerting  an  especially  favorable 
influence  upon  the  general  condition  and  with  exhibiting  no  serious 
secondary  effects,  I  have  as  yet  not  had  sufficient  experience,  by  reason 
of  the  slight  use  that  I  make  of  antipyretic  drugs.  Recently,  also 
Eichhorst^  has  warmly  praised  the  remedy  on  account  of  its  action 
upon  the  nervous  system,  particularly  its  sedative  influence  upon 
excited,  sleepless  patients. 

TREATMENT  OF  THE  DISORDERS  OF  INDIVIDUAL  ORGANS   AND 

SYSTEMS. 

The  treatment  of  the  disorders  of  the  circulatory  organs  has 

already  been  referred  to  frequently.  In  this  connection  the  symptoms 
due  to  impairment  of  cardiac  and  of  vasomotor  activity  are  especially 
to  be  taken  into  consideration.  How  successfully  these  are  coimter- 
acted  by  the  bath-treatment  and  how  little  of  a  favorable  character 
is,  on  the  other  hand,  to  be  expected  from  antipyretic  drugs,  which, 
on  the  contrary,  may  often  be  a  source  of  injury,  has  likewise  been 
sufficiently  emphasized. 

Should  progressive  enfeeblement  of  the  circulation  make  itself 
manifest,  in  spite  of  intelligently  employed  bathing-treatment,  further 
systematic  intervention  may  be  of  great,  and,  under  some  circum- 
stances, of  life-saving,  value.  The  first  place  should  be  taken  by  the 
employment  of  alcoholics.  Beginning  with  small  quantities  of  mild 
alcoholic  agents,  the  dose  and  the  strength  are  gradually  increased  in 
proportion  to  the  increase  of  the  collapse.  It  may  in  this  connection 
be  kept  in  mind  that  febrile  patients  bear  distinctly  larger  amounts  of 
alcohol  than  those  in  a  state  of  health.  Strong  wines,  old  Rhine  wine 
or  Burgundy,  Hungarian  wine,  port  wine,  and  sherry  are  mostly  used. 
Mulled  wine  and  champagne,  also  cognac  in  strong  coffee  or  tea  or  in 
the  form  of  Stokes's  mixture,  are  especially  efficient.  Patients  who 
swallow  badly  or  exhibit  a  distaste  for  alcohol  may  take  cognac,  under 
some  conditions  with  ethereal  tincture  of  valerian,  in  the  form  of  an 
enema  (cognac,  20  ;  ethereal  tincture  of  valerian,  5  ;  yolk  of  egg,  1 ; 
mucilage  of  gum  arable,  20  ;  water,  sufficient  to  make  150  ;  to  be  given 
in  two  or  three  parts  by  enema). 

Among  stimulating  drugs  I  employ  preferably  cafiein  (internally 

^  Prag.  med.   Woch.,  1894,  No.  11.  ^  Lehrbuch^  new  edition. 


464  TYPHOID  FEVER. 

and  subcutaneously),  and,  above  all,  camphor,  which  is  generally  most 
useful.  Its  internal  administration,  however,  is  disagreeable  to  the 
patient  and  is  useless.  I  therefore  employ  the  remedy  almost  solely 
subcutaneously.  The  official  (10  per  cent.)  camphorated  oil  or  a  stronger 
solution  may  be  used  for  this  purpose.  The  following  stronger  solution 
is  employed  at  my  clinic :  triturated  camphor,  2  ;  sulphuric  ether,  3  ; 
olive  oil,  7.^  In  accordance  with  the  gravity  of  the  situation,  one  or 
two  hypodermic  syringefuls  of  this  solution  may  be  given  every  hour 
or  two,  and  even  more  frequently.  I  have  never  observed  serious 
secondary  effects  from  its  use.  Probably,  in  some  cases,  the  method 
contributes  in  considerable  measure  to  the  successful  outcome.  Of  the 
subcutaneous  administration  of  pure  ether  I  rarely  make  any  use.  Its 
effect  is  distinctly  less  certain  and  persistent  than  that  of  camphor. 
In  addition,  the  injections  are  quite  painful,  and  not  rarely  give  rise  to 
necrosis  at  the  point  of  puncture.  Musk  has  largely  gone  out  of  use, 
and  it  appears  to  me  that  not  much  has  been  lost  in  consequence. 

At  times,  especially  in  hyperpyretic  cases,  an  ice-bag  applied  over 
the  heart  renders  good  service.  In  a  number  of  elderly  or  othersvise 
decrepit  individuals,  warmth  to  the  precordium,  preferably  applied  by 
means  of  Leiter's  tubes,  may  be  of  service.  Should  the  extremities 
become  cold,  the  application  of  bandages  and  hot  bottles  should  not  be 
neglected. 

Digestive  Organs. — The  care  of  the  mouth  and  the  nasophar- 
yngeal cavity  has  already  been  considered.  A  number  of  infectious 
disorders  of  the  larynx,  the  bronchi,  and  the  lungs  may  in  this  way  be 
averted.  That  artificial  teeth  should  be  removed  throughout  the  entire 
febrile  period,  especially  in  the  case  of  deeply  stuporous  patients,  is  a 
matter  of  course.  The  development  of  thrush  should  be  attacked 
vigorously  on  its  first  appearance.  In  the  presence  of  parotitis,  which 
frequently  subsides  without  the  occurrence  of  suppuration,  cold  cloths 
or  an  ice-bag  may  be  applied.  Should  suppuration  prove  inevitable, 
hot  poultices  should  be  applied,  and  then  free  incisions  be  made  as 
early  as  possible. 

The  intestinal  symptoms  are  generally  a  source  of  especial  anxiety. 
For  the  diarrhea,  which  generally  is  not  attended  with  marked  fre- 
quency of  bowel-movement  in  cases  of  typhoid  fever,  intervention 
should  be  undertaken  only  if  the  stools  are  unusually  numerous  and 
attended  with  peristaltic  unrest,  colicky  pain,  and  tenesmus — the  last 
occurring  more  commonly  in  cases  of  colotyphoid.     In  some  cases  it  is 

1  The  addition  of  the  ether  is  intended  only  for  the  purpose  of  making  the  mixture 
more  limpid,  and  therefore  more  available  for  injection. 


TREATMENT.  465 

then  advisable  to  withhold  milk  and  eggs  and  to  administer  only  small 
quantities  of  mucilaginous  soups  or  cocoa,  and,  in  addition,  under  cer- 
tain circumstances,  some  port  or  red  wine.  As  a  beverage,  weak  cold 
tea  is  much  to  be  preferred  to  the  gum-water  or  albumin-water  custom- 
arily employed.  An  ice-bag  upon  the  abdomen,  often  highly  praised 
in  this  connection,  is  rarely  well  borne.  Tepid  affusion  is  best.  Poul- 
tices may  be  permitted  only  under  special  conditions,  as  they  increase 
the  danger  of  the  occurrence  of  intestinal  hemorrhage. 

Of  drugs,  if  dietetic  measures  do  not  suffice,  I  employ  opium  almost 
solely,  giving  it  in  frequent  small  doses,  in  part  by  the  mouth,  in  part 
in  the  form  of  suppositories,  employing  the  latter  particularly  when  it 
is  thought  that  the  colon  and  the  cecum  are  especially  involved.  Little 
aid  is  to  be  expected  from  astringents.  Conversely,  persistent  consti- 
pation, which  is  by  no  means  uncommon,  may  require  intervention. 
Contrary  to  the  custom  of  a  number  of  other  clinicians  who  are  less 
strict,  I  never  employ  laxatives  mider  such  circumstances — not  even 
castor  oil  or  calomel,  which  are  in  great  favor.  Simple  enemata  of 
water  suffice,  as  a  rule. 

Marked  meteorism  in  patients  whose  dietary  has  not  be  neglected 
is  almost  always  the  expression  of  profound  intoxication.  Under  such 
conditions  tepid,  gradually  cooled  full  baths  are  especially  indicated, 
and  in  the  intervals  moist  affusions  or  an  ice-bag  should  be  applied  to 
the  abdomen.  Should  these  measures  affiDrd  no  relief,  not  much  depend- 
ence can  be  placed  upon  others.  I  have  observed  scarcely  any  good 
from  the  use  of  oil  of  turpentine,  externally  or  internally,  in  spite  of  its 
frequent  recommendation  by  early  practitioners.  The  highly  praised 
high  introduction  of  a  rectal  tube  also  will  be  successful  in  only  a 
minority  of  cases.  At  best,  I  have  been  able  to  evacuate  gas  through 
it  only  when  the  meteorism  was  confined  principally  to  the  large  intes- 
tine. When  especially  the  small  intestine  is  greatly  distended,  not  much 
will  be  accomplished  with  the  tube.  Direct  puncture  of  the  intestine 
with  a  fine  needle,  which  has  received  recommendation  from  various 
sources,  is  dangerous  on  account  of  the  liability  of  peritonitis.  At  any 
rate,  by  reason  of  the  marked  paresis  of  the  intestinal  tube,  almost 
always  present,  and  the  considerable  loss  of  elasticity  in  the  overdis- 
tended  abdominal  wall,  no  gas  will  escape  through  the  needle,  for 
obvious  physical  reasons. 

In  the  presence  of  intestinal  hemorrhage,  and  even  upon  the 
slightest  indication  thereof,  absolute  rest  in  the  dorsal  decubitus  is  neces- 
sary, and  the  abdomen  should  be  covered  with  an  ice-bag  or  a  coil  of 
cold  water.     The  patient  should  for  a  time  refrain  from  the  ingestion  of 

30 


466  TYPHOID  FEVER. 

all  food.  At  most,  bits  of  ice  or  cold  tea  in  spoonful  doses  may  be  given. 
If  the  hemorrhage  is  slight,  or  on  the  cessation  of  more  copious  hemor- 
rhage, a  spoonful  of  cold  milk,  or  a  corresponding  amount  of  mucilagi- 
nous soup,  may  be  given  every  two  or  three  hours.  Control  of  intes- 
tinal peristalsis  should  be  provided  for  by  means  of  opium,  in  frequent, 
even  heroic,  doses,  by  the  mouth  or  the  rectum.  In  tlie  presence  of 
general  restlessness,  one  should  not  hesitate  to  administer  a  subcuta- 
neous injection  of  morphin. 

The  drugs  recommended  as  direct  hemostatics  are  less  trustworthy. 
Some  employ,  with  good  results,  it  is  stated,  subdermal  injections  of 
ergotin.  Nothing  is  to  be  expected  from  internal  styptics  or  astrin- 
gents, especially  the  much-recommended  solution  of  ferric  chlorid. 
They  may,  on  the  contrary,  be  directly  dangerous,  from  the  fact  that  at 
times  they  excite  vomiting.  When  the  patients  become  feebler,  it  is 
wise  not  to  resort  to  the  use  of  strong  stimulants  too  early.  Moderate 
collapse,  if  intelligently  controlled,  may  be  favorable  to  thrombosis  of 
the  bleeding  vessel.  In  the  presence  of  considerable  cardiac  weakness 
followmg  profuse  hemorrhage,  these  considerations  may  naturally  be 
ignored.  Under  such  circumstances  the  treatment  already  described 
for  collapse  will  be  indicated.  In  some  especially  alarming  cases  I  have 
observed  good  results  follow  the  subcutaneous  or  intravenous  infusion 
of  sodium  chlorid,  and  even  from  transfusion  of  blood. 

The  use  of  calcium  chlorid  in  large  doses  (2  grams  every  three  or 
four  hours),  and  the  subcutaneous  injection  of  a  2  per  cent,  solution  of 
srelatin  in  order  to  increase  the  coagulabilitv  of  the  blood  and  so  favor 
thrombosis  in  the  bleeding  vessel,  have  been  lately  tried  at  the  Johns 
Hopkins  Hospital,  in  some  cases  apparently  with  good  results. 

Intestinal  Perforation.  —  Recently,  surgery  has  undertaken 
intervention  in  these  cases,  resulting  in  the  saving  of  life.  The  first 
attempts,  in  the  presence  of  perforative  peritonitis  complicating  typhoid 
fever,  to  open  the  abdominal  cavity,  to  search  for  the  site  of  perforation 
directly,  and  to  close  it,  and  then  to  make  a  thorough  toilet  of  the 
peritoneum,  are  due  to  Mikulicz  ^  and  Liicke."  They  have  been  followed 
by  a  large  number  of  surgeons,  some  of  whom,  especially  courageous, 
have  even  earnestly  recommended  resection  of  the  perforated  portion  of 
the  intestine. 


^  Volkmann^ s  Sammlung  klin.  Vorfrdge,  No.  262. 

2  Deuisch.  Zeii.f.  Chir.,  1887,  Bd.  xxv.;  and  Verhandl.  d.  deutschen  Gesellschaft 
f.  Chir.,  1889.  A  complete  bibliocjraphy  bearins:  upon  the  procedure  in  question  is 
given  by  Geselewitzsch  and  Wannack,  Mittheil.  ausden  Grenzgebietend.  Med.  u.  Chir., 
Bd.  ii.,  H.  1  u.  2,  S.  32,  et  seq. 


TREATMENT.  467 

The  details  and  methods  of"  operating  more  recently  employed  are 
fully  considered  in  the  writings  of  the  surgeons  referred  to  on  pages 
234,  235. 

In  view  of  the  excellent  results  obtained  by  the  use  of  this  procedure 
during  the  past  few  years,  and  since  the  chances  for  success  from  opera- 
tion are  far  greater  the  earlier  it  is  undertaken,  it  is  of  the  utmost 
importance  that  the  condition  be  recognized  early  ;  and  with  increase 
of  skill  in  early  diagnosis  will  undoubtedly  come  an  appreciable  reduc- 
tion in  the  mortality  from  this  accident.  The  attending  physician 
should  have  the  possibility  of  perforation  constantly  in  mind,  and  with 
the  onset  of  the  first  suspicious  symptoms  a  most  careful  examination 
should  be  made.  All  feeding  should  be  stopped  at  once,  all  forms  of 
bath-treatment  should  be  discontinued,  absolute  rest  should  be  main- 
tained, and  the  patient  should  be  watched  with  the  greatest  care  until 
all  possibility  of  the  existence  of  a  perforation  has  passed.  (In  regard 
to  early  diagnosis,  see  p.  234.)  The  use  of  opium  in  these  cases  is 
justifiable  only  after  the  diagnosis  has  been  made  and  operation  decided 
upon.  As  soon  as  perforation  is  believed  to  have  occurred,  immediate 
surgical  intervention  is  demanded.  The  results  of  this  procedure 
(p.  235)  fully  warrant  its  application  wherever  conditions  are  such  as  to 
render  laparotomy  for  any  other  condition  justifiable.  The  introduc- 
tion of  the  use  of  local  cocain-anesthesia  in  these  cases  by  Gushing  has 
been  a  distinct  advance,  in  that  it  has  made  the  operation  possible  in 
many  cases  in  which  the  administration  of  a  general  anesthetic  would 
of  itself  be  a  source  of  considerable  danger. 

Even  in  cases  in  which  the  perforation  has  not  been  recognized  early 
and  general  peritonitis  is  present,  hope  must  not  be  lost.  No  case  is  so 
desperate,  unless  actually  moribund,  as  to  be  without  some  hope  in  the 
hands  of  a  good  surgeon. 

Cholecystitis. — The  question  of  surgical  treatment  has  been  con- 
sidered by  the  authors  quoted  on  pages  209,  210.  Undoubtedly,  many 
of  these  cases  recover  without  such  interference.  However,  this  is  not 
true  of  a  majority  of  the  cases.  Of  44  cases  of  typhoidal  mfection  of 
the  gall-bladder  accompanying  or  following  typhoid  fever,  collected  by 
Keen,'  30  resulted  in  perforation.  Of  these  30  cases,  4  were  operated 
upon,  and  of  these,  3  recovered ;  while  of  the  remaining  26  not  operated 
upon,  all  died.  There  can  therefore  be  little  question  as  to  the  advisa- 
bility of  operation  as  soon  as  perforation  is  diagnosed.  As  to  operation, 
in  cases  of  cholecystitis  with  marked  distention,  before  perforation,  the 
opinion  of  Keen  ^  may  be  quoted  :   "  I  am  decidedly  of  the  opmion  that 

1  Loc.  cit.  2  Camac,  Johns  Hopkins  Hosp.  Rep.,  vol.  viii. 


468  TYPHOID  FEVER. 

in  distentiou  of  the  g-all-bladdcr  prompt  surgical  interference  is  the  best. 
It  is  far  better  to  prevent  perforation  than  to  remedy  it  after  it  has 
occurred." 

Operation  in  these  cases,  also  under  local  cocain-anesthcsia,  has  been 
done  bv  Gushing  and  by  Mitchell. 

Suppurative  cholecystitis  and  cholelithiasis  following  typhoid  fever 
should,  of  course,  receive  surgical  treatment. 

The  diseases  of  the  respiratory  organs  may  require  then- 
peutic  intervention.  IMarked  degrees  of  nose-bleed  are  worthy  of  atten- 
tion on  account  of  the  already  reduced  condition  of  the  patient  from 
other  causes.  A  number  of  deaths  have  resulted  from  the  circum- 
stance that  the  patients,  stuporous  or  sleeping  profoundly,  especially  if 
the  nasal  orifice  has  been  tamponed,  have  lost  an  immense  amount  of 
blood  into  the  nasopharyngeal  cavity  and  have  swallowed  it,  in  conse- 
quence of  which  the  hemorrhage  does  not  promptly  come  to  the  kuowl- 
edsre  of  the  attendants.  I  have  made  it  a  rule  in  severe,  obstinate 
cases  of  epistaxis  to  apply  tampons  not  alone  from  the  front,  but  also 
from  behind. 

The  treatment  of  the  typhoid  lesions  of  the  larynx  has  already 
given  rise  to  an  extensive  literature.'  It  treats  especially  of  the  indi- 
cations for  and  the  performance  of  tracheotomy,  with  which,  in  severe 
cases,  there  should  be  no  delay.  The  operation,  however,  has  also  its 
dark  side,  especially  in  cases  of  typhoid  fever,  inasmuch  as  in  them, 
far  more  than  in  those  free  from  fever,  it  favors  the  development  of 
pneumonia,  both  by  aspiration  and  by  retention  of  secretion. 

One  must  always  be  prepared  for  the  development  of  abscess  of  the 
thyroid  gland,  on  account  of  its  gravity,  but,  fortunately,  it  is  not  fre- 
quent. It  soon  gives  rise  to  attacks  of  suflPocation,  and  it  should 
therefore  be  incised  as  early  as  possible. 

By  far  the  best  treatment  for  typhoid  bronchitis  is  that  with  baths, 
cold  friction,  and  moist  applications.  I  scarcely  ever  use  the  so-called 
expectorants — ipecacuanha,  senega,  etc.  When  importance  is  attached 
to  the  use  of  drugs,  the  administration  of  liq.  ammon.  anis.  is  least 
injurious.  Should  symptoms  of  cardiac  weakness  be  added  to  those  of 
bronchitis,  measures  directed  especially  to  the  prevention  of  pulmonary 
hypostasis  are  indicated.  Under  such  circumstances  frequent  change 
of  position  should  be  brought  about,  and  an  endeavor  should  be  made 
to  improve  the  enfeebled  cardiac  activity.  In  some  cases  the  applica- 
tion of  dry  cups  over  the  region  of  the  lower  lobes  renders  good  service. 

'  See  the  references  on  page  239  and  the  following  pages  of  this  work,  especially 
the  exhaustive  work  of  Liining  there  mentioned  (p.  243j. 


TREATMENT.  469 

The  treatment  of  disorders  of  the  nervous  system  is,  as  has 
already  been  pointed  out,  likewise  one  of  the  principal  uses  of  hydro- 
therapy. A  number  of  drugs  also  (quinin,  anti{)yriu,  phenacetin,  and 
lactophenin)  appear  to  render  valuable  service  in  this  connection.  In 
addition  to  the  general  antipyretic  treatment,  special  measures  and  modi- 
fications of  hydrotherapeutic  methods  may  become  necessary.  Severe 
headache  during  the  first  period  of  the  disease  should  be  relieved  by 
means  of  the  ice-bag,  Leiter's  coils,  or  by  placing  the  head  upon  water- 
cushions  kept  constantly  cool.  Under  such  circumstances  a  dose  of 
antipyrin  or  phenacetin  also  often  yields  the  best  results. 

At  a  later  period  of  the  disease  the  sensitive  states  of  the  nervous 
system  and  the  depressive  states — coma,  sopor,  stupor  with  cataleptic 
symptoms — often  require  special  treatment.  The  depressive  conditions, 
when  they  attain  a  considerable  degree  of  severity,  should  be  controlled 
by  means  of  cold  douches  in  the  tepid  bath,  and,  in  particularly  robust 
persons  and  when  the  attack  pursues  a  hyperpyretic  course,  even  by  means 
of  quite  cold  full  baths.  A  useful  adjunct  under  such  conditions  con- 
sists at  times  in  the  enemata  of  valerian  and  cognac  previously  men- 
tioned. In  the  presence  of  marked  irritative  states — delirium,  attempts 
at  flight,  and  sleeplessness — protracted,  simple  tepid  or  gradually  cooled 
von  Ziemssen  baths  are  indicated.  Cold  douches  and  similar  measures 
rarely  do  good  under  such  circumstances.  Greatly  debilitated  indi- 
viduals may  be  treated  advantageously  with  tepid  wet-packs  in  place 
of  the  baths,  but  in  order  to  secure  the  necessary  rest  for  the  patient 
the  packs  should  be  changed  infrequently.  If  restlessness  be  par- 
ticularly marked,  one  should  not  hesitate  to  give  moderate  doses  of 
morphin ;  they  never  do  harm,  and  they  help  to  protect  the  brain  from 
exhaustion.  In  drunkards,  alcohol  should  be  given  generously,  in 
addition  to  morphin. 

Of  the  organs  of  special  sense,  the  ear  particularly  should  be 
given  consideration.  In  profoundly  stuporous  patients  frequent  exami- 
nation is  necessary,  even  though  they  make  no  complaint.  Should 
inflammation  of  the  middle  ear  develop,  the  early  performance  of  para- 
centesis of  the  tympanic  membrane  is  recommended  by  most  aurists. 

External  Integtinient. — With  the  present  system  of  nursing, 
the  occurrence  of  bed-sores,  even  in  severe,  protracted  cases,  is  excep- 
tional. Profoundly  ill  patients  should,  from  the  beginning  of  the  second 
week,  be  placed  upon  a  water-bed,  as  von  Ziemssen  and  Imraermann  first 
recommended.  If  this  be  combined  with  the  strictest  cleanliness  and 
appropriate  bath-treatment,  bed-sores  can  almost  certainly  be  avoided. 
Placing  the  patient  upon  air-cushions  likewise  is  usually  sufficient. 


470  TYPHOID  FEVER. 

Air-cushions  and  water-cushions  shoukl  always  be  covered  with  a  sheet 
free  from  folds  and  of  not  too  coarse  texture.  They  should  never  be  unduly 
filled — in  general,  only  to  such  a  degree  as  not  to  rise  above  the  level  of  the 
remainder  of  the  bed  when  the  patient  lies  upon  them.  I  have  water-cush- 
ions filled  only  with  tepid  water  ;  the  use  of  cold  water  is  unnecessary  and 
disagreeable  to  most  patients. 

If  a  typhoid  patient  presents  a  bed-t^ore  when  he  comes  under 
observation,  or  if  such  a  condition  cannot  be  prevented,  in  spite  of  the 
utmost  care,  it  should  be  treated  in  accordance  with  the  rules  of  anti- 
sepsis. The  application  of  plasters,  formerly  practised,  is  to  be  rejected, 
on  account  of  the  danger  of  retention  of  the  secretions  of  the  wound. 
Dressings  with  borated  or  other  antiseptic  ointments  are  most  suitable. 
The  fortunately  extremely  rare  cases  of  very  extensive,  multiple,  and 
progressive  bed-sores,  attended  with  general  nutritional  disturbances, 
can  at  times  be  favorably  influenced  by  treatment  in  a  permanent 
water-bath. 

The  treatment  of  erysipelas,  furuncles,  and  phlegmons  should  be 
carried  out  in  accordance  with  general  rules. 

With  reference  to  typhoid  aflFections  of  the  kidneys,  it  need 
only  be  remarked  that  they  do  not  contraindicate  mild  bath-treatment, 
while  under  such  circumstances  certain  antipyretic  drugs,  particularly 
salicylates,  are  strictly  to  be  avoided.  That  the  bladder  should  be 
frequently  examined  in  the  case  of  profoundly  stuporous  typhoid 
patients,  and  if  necessary  catbeterized,  cannot  be  too  deeply  impressed 
upon  the  young  physician.  When  bacilli  are  present  in  the  urine,  as 
demonstrated  by  cultures  or  shown  by  the  microscope,  urotropiu  should 
be  given  in  10-grain  doses. 

With  regard  to  the  treatment  of  especial  varieties  of  typhoid 
fever  some  statements  have  already  been  made.  The  hyperpyretic 
variety  requires  especially  keeping  the  patient  in  a  cool  state,  frequent 
cool  baths,  and  not  rarely  antipyretics,  among  which  I  prefer  quinin. 
In  the  varieties  attended  with  septic  manifestations  I  have  at  times 
obser^^ed  good  results  from  the  use  of  frequent,  fairly  large  doses  of 
antipyrin.  The  so-called  hemorrhagic  variety  has  as  yet  proved  little 
amenable  to  treatment.  The  use  of  calcium  chlorid  and  the  subcutane- 
ous injection  of  gelatin  solution  should  be  tried.  The  highly  lauded 
employment  of  ergot  and  the  acids  is  worthy  of  little  confidence.  The 
conditions  present  consist  in  profound  disturbances,  which,  so  long  as 
they  are  not  understood  etiologically,  are  not  accessible  therapeutically. 
That  mixed  forms  of  typhoid  fever  and  malaria  demand  energetic  treat- 
ment with  quinin  need  scarcely  be  specially  emphasized. 


TREATMENT.  All 

TREATMENT  OF  RECRUDESCENCES  AND  RELAPSES. 

We  have  already  learned  to  appreciate  the  ,seri<m,s  prognosis  of  true 
recrudescences.  Their  treatment  is  the  same  as  that  of  the  severe 
typhoid  state  in  general,  with  especial  consideration  fr)r  the  circum- 
stance that  the  patients,  already  greatly  reduced  in  consequence  of  the 
antecedent  period  of  disease,  are  predisposed  to  cardiac  weakness,  pul- 
monary hypostasis,  and  states  of  profound  nervous  exhaustion.  Only 
the  mildest  hydro  therapeutic  measures  can  be  employed.  Cold  full 
baths,  douches,  and  the  like  are  entirely  to  be  avoided.  The  most 
important  consideration  under  these  circumstances  is  suitable  nourish- 
ment and  abundant  administration  of  stimulants,  especially  alcohol. 
The  relapses,  which,  on  the  contrary,  are  of  favorable  prognosis,  require 
treatment  only  when  they  are  abnormally  protracted  or  when  a  severe, 
long-continued  relapse,  following  a  mild,  at  times  ambulatory,  primary 
attack,  constitutes  actually  the  principal  part  of  the  entire  disease. 
Under  such  circumstances,  naturally,  the  rules  already  laid  down  for 
the  primary  attack  are  applicable. 

Whether  relapses  can  be  prevented  when  their  imminence  is  to  be 
feared  on  account  of  the  persistence  of  enlargement  of  the  spleen  and 
of  the  diazo-reaction  into  the  afebrile  period,  as  well  as  the  relation 
between  the  pulse  and  the  temperature  previously  mentioned,  is  doubted 
by  many.  I  believe  with  von  Ziemssen  that  this  is  possible  at  times 
by  appropriate  treatment  with  quinin.  Under  such  circmnstances  I  do 
not,  however,  administer  single  large  doses,  but  smaller — from  0.25  to 
0.5  gram — four  times  daily,  and  occasionally  even  more  frequently. 
The  same  treatment  has  been  serviceable  also  in  cases  in  which,  with  or 
without  persistence  of  enlargement  of  the  spleen,  the  temperature-curv^e 
acquires  a  wholly  irregular  character,  and  with  normal  or  subnormal 
daily  temperature  exhibits  moderate  elevation  toward  evening.  I 
believe  that  I  have,  by  means  of  treatment  with  quinin,  materially 
shortened  the  duration  of  a  number  of  such  cases,  which  experience 
had  shown  might  be  prolonged  indefinitely. 

TREATMENT  OF  CONVALESCENCE. 

A  principal  point  in  the  treatment  of  convalescence,  attention  to  the 
nutrition,  has  already  been  referred  to  (p.  451).  Not  less  closely 
than  this  should  also  the  general  physical  and  mental  condition 
of  the  patient  be  watched.  He  should  not  be  permitted  to  get  out  of 
bed  too  soon ;  and  it  is  well,  both  for  the  patient  and  for  the  friends, 
from  the  outset  to   name  the  much-longed-for  day  rather  too   far  in 


472  TYPHOID   FEVER. 

advance.  Evcu  after  mild  attacks  eouvaleseeuts  should  uot  be  per- 
mitted to  get  out  of  bed  earlier  than  two  weeks  after  definite  defcr- 
vescenee.  After  severe  attacks  this  goal  will  scarcely  be  reached  before 
the  lapse  of  four  weeks.  Complications  often  require  rest  in  bed  for 
even  much  longer  periods.  The  patient  aud  the  friends  should  be 
clearly  instructed  that  the  course  of  convalescence  is  not  less  dependent 
upon  strict  obedience  than  is  that  of  the  previous  stages. 

In  bed  the  convalescents  should  remain  as  quiet  as  possible  and 
avoid  sitting  up  too  long,  particularly  in  the  first  part  of  the  afebrile 
period  (collapse).  AMth  regard  to  the  mental  state,  they  should,  so 
long  as  j)ossible,  be  kept  away  from  severe,  particularly  technical,  read- 
ing, while  light,  indifferent  literature  may  be  read  to  them.  Visits 
also  should  be  restricted  during  convalescence,  and  only  such  persons 
admitted  as  do  not  excite  the  patient  and  do  not  encourage  him  to  par- 
ticipate actively  in  the  entertainment.  How  injurious  such  visits  may 
be  is  shoA\Ti  in  hospitals  by  the  temperature-curves  of  convalescents  on 
the  official  visiting  days.  It  is  a  useful  aud  a  welcome  substitute  for 
much  that  is  forbidden  to  bring  the  convalescent  in  bed  into  the  open 
air,  if  the  weather  is  favorable. 

When,  after  convalescence  has  been  completed,  the  USUal  activi- 
ties may  be  resumed  cannot  be  determined  in  general,  but  must  be 
decided  according  to  the  individual  case.  The  nature  of  the  attack  that 
has  been  passed  through,  the  character  of  the  occupation,  the  constitu- 
tion, and  other  external  social  conditions  play  the  decisive  role  in  this 
connection. 

Persons  in  favorable  pecuniary  circumstances  may  be  recommended 
to  take  a  long  holiday  before  resumption  of  ^^'ork.  For  this  pm-pose  it 
is  best  to  select  a  moderate  mountainous  elevation  or  a  mild  seaside 
resort.  Considerable  altitudes  (above  1000  meters)  or  rigorous  sea- 
baths,  particularly  in  the  German  Sea,  are  in  general  to  be  interdicted. 
In  winter  a  residence  in  the  South,  in  Southern  Tirol,  at  the  upper 
Italian  lakes,  or  the  Riviera  is  appropriate.  The  Isle  of  Wight  is  also, 
under  certain  circumstances,  a  suitable  resort  for  recuperation.  Those  of 
moderate  means  should,  at  least  after  severe  attacks  of  typhoid  fever, 
spend  some  time  in  the  countr}^  The  efforts  that  are  becoming  more 
and  more  evident  to  provide  for  the  less  well-to-do  classes  by  the  erec- 
tion of  sanatoria  in  the  country  are  to  be  cordially  welcomed. 


TYPHUS  FEVER. 


TYPHUS   FEVER. 


Typhus  fever  is  an  acute  infectious  disease,  the  hitherto  undis- 
covered cause  of  which  reproduces  itself  exclusively  in  the  body  of  the 
individual  affected.  The  disease  originates  and  spreads  only  by  contact 
either  directly  with  the  patient,  or  indirectly  with  a  tliird  person  or 
with  an  inanimate  object  infected  with  the  germs  of  the  disease. 

Being  exceedingly  contagious,  it  is,  therefore,  usually  epidemic. 
Occasionally,  when  the  external  or  personal  circumstances  of  the  popu- 
lation make  it  difficult  for  the  contagium  to  obtain  a  foothold,  or  when 
the  proper  prophylactic  measures  have  been  carried  out  in  good  season, 
it  may  be  endemic  or  sporadic.  Typhus  fever  ^  has  no  connection  what- 
ever with  typhoid  fever.^  It  belongs,  in  fact,  to  another  group  of  infec- 
tious diseases,  the  acute  exanthemata,  which  it  resembles  in  the  extra- 
ordinary ease  with  which  it  is  transmitted  by  direct  contact  from  one 
individual  to  another,  by  its  self-limited  course,  by  the  rare  occurrence 
of  relapses,  by  the  peculiar  character  of  the  temperature-curve,  and  by 
the  fact  that  the  characteristic  eruption  appears  at  once  instead  of  in 
successive  crops. 

HISTORIC 

The  plan  of  this  work  does  not  include  a  detailed  description  of  the 
history  and  geographic  distribution  of  typhus  fever.  These  subjects 
have  been  carefully  treated  by  a  number  of  authors,  especially  Murchi- 
son  and  August  Hirsch,  and  their  description  is  so  complete  that  later 
writers  have  done  little  more  than  quote  from  their  works  without  add- 
ing anything  of  their  own. 

Typhus  fever  is  one  of  the  diseases  that  were  probably  known  to 
antiquity.       It    is    possible    that    even   Hippocrates^   encountered    the 

1  The  synonyms  for  typhus  fever  are :  Spotted  typhus,  exanthematic  typhus, 
typhus  contagiosus,  febris  pestilens,  febris  putrida,  febris  petechialis,  morbus  pulicaris, 
typhus  carcerum  (jail  fever),  febris  bellica,  febris  castrensis  (camp  fever i,  febris 
nautica  (ship  fever),  ship  typhus,  hunger  typhus,  and  febris  Hungarica  (Hungarian 
fever). 

*  The  term  typhus,  as  well  as  other  names  by  which  it  is  known,  such  as  spotted 
typhus,  exanthematic  typhus,  petechial  typhus,  etc.,  came  into  vogue  at  a  time  when 
the  disease  was  imperfectly  understood,  and  should  therefore  be  discarded. 

^  De  morb.  popuL,  lib.  ii.,  iii. 

475 


476  TYPHUS  FEVER. 

disease,  and  some  investigators  claim  to  have  found  passages  that  seem 
to  refer  to  it  iu  the  writintrs  of  Aetiiis,  Rhazes,  and  Avicenna. 

Tlie  earliest  unmistakable  reports  date  from  the  middle  ages,  and 
are  bv  many  authors  ascribed  to  Jacobus  de  Partibus  (1463)  and  the 
German,  Agricola.  Before  that  date,  and  for  some  time  afterward,  the 
disciise  was  confounded  with  certain  epidemic  infectious  diseases,  espe- 
cially the  plague.  Thus,  the  "  jilague "  (pest)  which  originated  in 
Cyprus  in  the  years  1505—28  and  ravaged  almost  tlie  whole  of  Italy 
was  undoubtedly  typhus  fever  ;  this  is  probably  true  also  of  the  disease 
called  morbus  Hungaricuti,  which  raged  in  the  army  of  Charles  the 
Fifth  during  the  siege  of  Metz,  in  the  year  1552.  The  appearance  of 
the  disease  in  Italy  at  that  time  found  a  historian  in  Frascatorius,  to 
whom  is  due  the  credit  for  the  first  lucid  description  of  typhus,  posi- 
tively distinguishing  it  from  other  diseases,  especially  the  plague.  He 
called  it  uiorbus  hnticularis. 

Hildenbraud  believes  that  a  number  of  other  diseases  designated  as 
the  plague  (pest)  iu  the  sixteenth  and  seventeenth  centuries  were 
undoubtedly  epidemics  of  typhus  fever — as,  for  instance,  the  plague  in 
Hungary  iu  1556 — febris  Hungarica  or  pannonica ;  the  plague  in 
Meissen  in  1574;  the  plague  in  Denmark  (1613—52);  and  the  plague 
in  Leyden  in  1669.  Numerous  other  epidemics  of  later  times — as,  for 
instance,  the  '^  Faulfieber/'  reported  by  Hasenohrl,  that  raged  in  and 
about  Vienna  in  the  years  1757  and  1759,  and  the  epidemic  of  ''  Faul- 
Jieber"  that  spread  overall  the  German  provinces  in  1771  and  1772 — 
are  with  reason  regarded  by  the  same  authority  as  contagious  typhus. 

In  every  century  typhus  fever  has  followed  in  the  wake  of  armies. 
During  the  thirty  years'  war  it  claimed  more  victims  than  did  the 
weapons  of  the  contestants.  It  was  the  terror  of  the  Napoleonic  cam- 
paigns, and  decimated  the  French  army,  already  demoralized  physically 
and  morally  by  the  terrible  retreat  from  Moscow. 

After  the  campaigns  of  1793  and  1794  the  scourge  visited  the 
whole  of  Germany.  In  1796  and  1797  it  broke  out  again,  and  after 
the  great  campaigns  of  the  year  1805,  it  became  epidemic  throughout 
Gallicia,  Hungary,  and  the  Austrian  crown-lands.  The  writings  of 
Rennebaum,  Schafer,  Hecker,  Rasori,  Larrey,  Hufeland,  Horn,  and 
especially  the  famous  monograph  of  Hildenbrand,  which  to-day  stands 
as  a  pattern  of  epidemiology,  refer  to  the  above-mentioned  epidemics  of 
the  end  of  the  eighteenth  and  the  beffinninsr  of  the  nineteenth  century. 

After  1830  the  disease  abated  on  the  European  continent,  notably 
in  Germany,  while  in  Irelaud  and  England,  where  the  disease  has 
always  been  prevalent,  it  continued  unabated  and  occasionally  broke 


HISTORIC.  477 

out  iu  extensive  epidemics.  From  1816  to  1818  the  disease  raged 
throughout  England  and  Ireland,  In  Ireland  alone  an  eighth  part  of 
the  entire  population  was  affected,  and  in  Dublin  as  many  as  a  third 
of  the  inhabitants  were  attacked.      Over  40,000  deaths  were  recorded. 

The  years  1826  and  1828  again  witnessed  severe  epidemics  in  both 
countries.  In  the  thirties  Ireland  suffered  most,  and  in  the  beginning 
of  the  following  decade  Scotland  chiefly  was  attacked.  In  1840,  the 
year  of  famine,  an  unusually  severe  epidemic  broke  out  in  Ireland,  and 
this  was  carried  to  England,  where  it  reached  its  highest  point  in  1847, 
and  continued  until  the  end  of  the  following  year.  It  is  a  fact  that 
seems  incredible  that  during  that  time  more  than  1,000,000  cases  of 
typhus  occurred  in  England,  and  more  than  300,000  in  Ireland 
(Murchison). 

During  these  two  decades  the  opinion  that  typhus  had  been  perma- 
nently superseded  by  typhoid  fever  gradually  gained  ground  in  Ger- 
many. This  illusion  was  dispelled  by  the  epidemics  of  1847  and  1848. 
Upper  Silesia  in  1847  was  the  first  to  suffer  a  severe  outbreak  of  the 
disease.  To  Virchow  we  owe  a  classic  description  of  the  epidemiologic 
and  social  conditions  of  that  period. 

The  later  wars  of  the  nineteenth  century,  like  the  campaigns  of  the 
first  Napoleon,  were  characterized  by  the  appearance  of  the  scourge. 
During  the  Crimean  war  it  decimated  both  the  French  and  the  English 
armies,  especially  the  former,  as  even  at  that  time  hygienic  measures 
were  far  better  understood  and  carried  out  in  the  English  camp.  From 
the  Crimea  the  disease  was  carried  into  France,  where,  as  in  Germany, 
the  people  had  up  to  that  time  supposed  that  they  were  secure  from  the 
disease. 

The  Italian  campaign  of  1861  and  the  Turko-Russian  war  of  1878 
contributed  a  number  of  victims.  Judging  from  Michaeli's  description, 
the  sanitary  conditions  in  the  Russian  army  must  have  been  appalling, 
and  far  worse  even  than  during  the  Crimean  war.  According  to  this 
author,  of  200,000  patients,  at  least  50  per  cent,  were  attacked  by 
typhus  fever,  and  half  of  those  attacked  succumbed  to  the  disease. 
During  this  epidemic  the  surgeons  were  the  worst  sufferers,  the  mor- 
tality among  them  reaching  60  per  cent. 

During  the  Franco-Prussian  war,  on  the  other  hand,  the  armies 
remained  entirely  free  from  typhus,  thus  affording  a  striking  proof  that 
the  disease  is  caused  not  so  much  by  the  massing  and  mobilization 
of  large  numbers  of  men,  as  by  their  continued  presence  in  regions 
where  the  disease  is  either  endemic  or  happens  to  be  raging  at  the 
time. 


478  TYPHUS  FEVER. 

Ill  France,  where  the  disease  has  never  taken  a  firm  foothold,  its 
recent  appearance  auain  destroyed  tlie  ilhision  that  French  soil  Avas  not 
favorable  to  its  development.  In  1893  an  epidemic  broke  ont  in  Lille. 
The  disease  was  carried  to  the  prisons  of  Paris,  whence  it  spread  to  the 
city  and  snrronndiugs. 

After  the  epidemics  of  1847  and  1848,  typhns  fever  continued  to 
lingier  in  certiiin  regions  of  Germany  until  the  beginning  of  the  eighties. 
Since  that  time  it  has  become  endemic  in  Upper  Silesia,  and  in  1867  it 
estal)lished  itself  in  Eastern  and  Western  Prussia.  The  disease  is  fed 
constantly  from  the  neighboring  Polish  provinces  of  Russia,  and  at 
intervals  it  invades  Germany,  travelling  in  a  direction  from  east  to 
west,  and  spreading  over  the  entire  country.  It  is  to  be  observed, 
however,  that  the  intensity  and  distribution  of  the  disease  constantly 
diminish  in  the  same  direction,  and  it  is  only  in  the  eastern  portions  of 
Germany,  particularly  in  the  frontier  districts,  that  large  endemic  or 
epidemic  outbreaks  occur.  AVhen,  in  the  years  1867  and  1868,  the 
diseiise  was  carried  into  Eastern  and  Western  Prussia  by  vagabonds,  it 
swelled  to  enormous  epidemics.  Thus,  in  the  district  of  Gumbinnen 
alone  4000  cases  were  reported  (Guttstadt).  During  the  period  from 
1875  to  1882  the  eastern  provinces  and  parts  of  Central  Germany  were 
visited  by  a  severe  outbreak  of  typhus  fever ;  and  during  the  five  years 
from  1877  to  1882  Guttstadt  reported  10,1300  cases  admitted  to  the 
Prussian  hospitals. 

In  all  the  more  extensive  epidemics,  Berlin  and  the  larger  cities  of 
Northeastern  and  Southeastern  Germany,  such  as  Konigsberg,  Stettin, 
Danzig,  Breslau,  etc.,  were  invaded  to  a  greater  or  less  extent.  In 
every  case  the  approach  of  the  disease  was  from  the  east,  and,  fortu- 
nately, it  never  succeeded  in  obtaining  a  permanent  foothold.  In 
Berlin  particularly,  after  1870,  the  disease  appeared  almost  every  year, 
coming  usually  from  Eastern  and  Western  Prussia  and  Pomerania,  the 
first  stopping-place  'of  the  epidemic  on  its  march  from  east  to  west.  It 
spread  among  the  class  of  inhabitants  by  whom  it  is  usually  carried — 
that  is,  vagabonds  and  persons  out  of  work  and  without  shelter. 
Charitable  institutions,  prisons,  and  the  lowest  variety  of  inns,  known 
as  "  ]>ens  "  (Pennen),  were  the  chief  foci  of  the  disease.  The  better 
part  of  the  population,  those  who  possess  a  permanent  domicile,  were 
attacked  only  to  a  very  slight  extent,  and  these  cases  could  almost 
always  be  traced  to  direct  contact  with  typhus  patients. 

During  the  ])eriod  from  1876  to  1879  I  Avas  superintendent  of  the 
Berlin  pest-house,  the  lazaretto  in  Moabit,  and  there  enjoyed  abundant 
opportunity  for  studying  the  disease.     I  have  the  reports  of  677  cases 


insTOPJC.  479 

dating  from  that  time.  Later  I  saw  a  few  sporadic  cases  in  Hamburg 
and  Leipsic,  brought  by  emigrants  from  Poland  and  Russia.  The  fol- 
lowing description  of  the  disease  is  based  on  a  study  of  these  epidemics 
and  of  a  number  of  sporadic  cases,  occurring  chiefly  in  my  j)rivatc 
practice,  that  were  of  especial  importance  from  the  standpoint  of  differ- 
ential diagnosis. 


ETIOLOGY. 


ORIGIN  AND  MODE  OF  TRANSMISSION  OF  THE 
CONTAGIUM. 

Typhus  fever  is  one  of  the  most  contagious  diseases  known  to  medi- 
cine. It  originates  and  spreads  to  predisposed  individuals  solely  by  the 
direct  or  indirect  transmission  of  the  specific  contagium,  developing  in 
the  body  of  the  patient.  The  mode  of  transmission  and  entrance  of 
the  contagium  into  the  body,  although  not  as  yet  accurately  known,  is 
undoubtedly  in  all  essentials  similar  to  that  which  obtains  in  the  acute 
exanthemata — small-pox,  scarlet  fever,  measles,  etc. 

The  possibility  of  the  contagium  of  typhus  fever  originating  outside 
and  independently  of  the  body  of  the  patient  is  no  more  conceivable 
than  is  the  spontaneous  production  of  typhoid  fever. 

Long  ago,  at  a  time  when  a  non-specific  origin  of  typhus  fever  was  con- 
sidered possible  and  even  usual,  the  contagiousness  of  the  disease  in  the 
modern  sense  was  upheld  by  a  few  physicians,  notably  by  Budd,  who  was 
far  in  advance  of  his  time.  His  teachings,  however,  were  not  al)le  to  dispel 
entirely  the  theory  of  miasmatic  origin,  which  survived  until  a  very  much 
later  date.  Murchison  himself,  who  acknowledged  that  the  essential  points 
in  the  disease  are  the  specificity  of  the  poison  and  its  reproduction  in  the 
body  of  the  patient,  devotes  some  sj;ace  to  the  possibility  of  an  independent, 
spontaneous  origin,  a  theory  that  even  Griessinger,  with  all  his  acumen,  does 
not  quite  venture  to  discard.  He  believes  that  in  rare  cases,  especially  when 
the  disease  breaks  out  in  isolated  places,  as  on  shipboard,  in  prisons,  etc.,  in 
the  absence  of  typhus  patients,  "  recourse  must  be  had  to  the  obscure  realms 
of  the  miasma." 

Long  after  Griessinger,  Jaccoud  '  maintained  that  spontaneous  production 
was  possible  and  occurred  not  infrequently. 

In  quite  recent  times  Kelsch  again  showed  a  leaning  toward  the  same 
theory,  believing  that  certain  innocuous  germs  in  the  body  may,  under  suit- 
able external  conditions,  assume  a  great  specific  virulence. 

Owdng  to  the  extreme  facility  with  which  the  disease  is  carried  from 
individual  to  individual,  sporadic  cases  of  typhus  fever  are  very  rare. 
The  disease  is  almost  ahvays  endemic  or  distinctly  epidemic,  and  under 
unusually  favorable  conditions,  especially  when  large  numbers  of  men 
are  massed  together  in  social  or  military  destitution,  the  number  of 
individuals  attacked  is  rarely  equalled  or  exceeded  by  any  of  the  other 

1  Gaz.  Heb.,  1875;  and  Fatol.  int.,  1877. 
480 


ETIOLOGY.  481 

infectious  diseases.  The  most  extensive  epidemics  are  observed  when 
the  disease  is  carried  from  a  country  where  it  is  endemic  into  a  district 
usually  free  from  the  disease,  and  which  therefore  does  not  possess  any 
immunity ;  or,  conversely,  when  large  numbers  of  predisposed  indi- 
viduals travel  from  such  regions  to  countries  where  the  disease  is 
endemic,  as  occurs  in  emigration  or  during  war. 


GEOGRAPHIC. 

In  regard  to  the  endemic  distribution  and  permanence  of  typhus 
fever,  England  and  Ireland  occupy  the  first  place  among  the  countries 
of  Europe.  The  disease  never  dies  out  completely  in  these  countries, 
where  it  is  the  predominant  form  of  "  typhoid  "  disease.  The  disease 
is  occasionally  carried  from  the  shores  of  Ireland  and  England  to 
neighboring  countries,  particularly  to  countries  with  which  England 
maintains  an  active  commercial  intercourse,  and  that  are  usually  free 
from  the  disease  and  from  the  conditions  that  favor  its  becoming 
endemic.  Such  countries  are  Sweden  and  Norway,  Belgium,  Holland, 
North  America,  and,  to  some  extent,  France,  whither,  during  this  cen- 
tury, the  disease  has  frequently  been  carried  from  other  countries  as 
well,  notably  from  Russia. 

With  the  exception  of  a  few  districts  in  the  Southeast,  such  as 
Upper  Silesia,  Germany  is  usually  quite  free  from  the  disease.  When 
an  outbreak  occurs,  it  is  almost  always  derived  from  the  eastern  coun- 
tries, especially  Russia,  in  many  parts  of  which,  particularly  in  the 
Baltic  and  Polish  provinces,  unfortunately  for  Germany,  the  disease  is 
endemic. 

In  Hungary,  Turkey,  and  the  adjoining  Oriental  coimtries  the 
disease  apparently  never  becomes  quite  extinct. 

Various  parts  of  Italy  have  been  visited  repeatedly  by  obstinate 
epidemics  of  typhus  fever.  It  has  appeared  m  Piemont,  Tuscany, 
Naples  and  its  surroundings,  Sicily,  and  Sardinia.  In  the  two  last- 
named  islands  the  disease  seems  never  to  disappear  entirely. 

Spain  and  Portugal,  owing  to  their  geographic  position,  are  rela- 
tively free  from  the  disease,  although  mild  outbreaks  have  occurred, 
the  last  one  in  Portugal  in  1880. 

In  Africa  the  disease  has  been  observed  chiefly  in  the  maritime  por- 
tions that  carry  on  an  active  trade  with  Europe.  In  Algiers,  where  it 
appeared  for  the  first  time  in  the  early  sixties  of  the  last  century,  it 
seems  to  have  become  endemic. 

Persia  and  China  are  never  free  from  its  unwelcome  presence,  the 

31 


482  TYPHUS  FEVER. 

misery  and  squalor  of  the  inhabitants  furnishing  abundant  opportunity 
for  the  occurrence  of  the  tlisease. 

India  appears  to  be  rehitively  free.  Murchison  coukl  not  determine 
to  his  entire  satisfaction  whether  the  reports  that  he  collected  from  that 
country  really  referred  to  typhus  fever  or  not ;  the  reports  of  more 
recent  times  are  also  equally  unsatisfactory. 

THE   NATURE  AND  MODE   OF   ACTION  OF  THE  TYPHUS  FEVER 

CONTAGIUM. 

The  foregoing  remarks  on  the  geography  and  history  of  the  disease 
will  suffice  to  show  the  enormous  diifereuces  between  typhus  and  typhoid 
as  regards  origin  and  spread.  Whereas  typhoid  fever  is  found  in  almost 
all  the  countries  of  the  earth,  and  is  nowhere  distinctly  endemic,  this 
quality  of  endemicity  is  peculiarly  characteristic  of  typhus  fever ;  and 
whereas,  owing  to  the  nature  and  mode  of  spread  of  its  contagium, 
typhoid  fever  gives  rise  to  severe  epidemics  only  under  very  special 
circumstances,  and  occurs  almost  always  sporadically  or  in  circumscribed 
areas,  the  fugaciousness  of  the  typhus  poison  and  the  ease  with  which 
it  is  transported  through  the  air  by  inanimate  carriers  lead  to  rapid  and 
widespread  distribution  of  the  disease  when,  in  a  given  case,  it  is  car- 
ried into  a  non-infected  country  whose  inhabitants  are  predisposed  to  it 
by  imperfect  development,  starvation,  or  the  miseries  of  war. 

Bacteriology. — Although,  as  has  been  remarked,  we  are  quite 
certain  that  the  contagium  of  typhus  fever  is  a  specific  poison,  elaborated 
solely  within  the  body  of  the  patient,  and  therefore  undoubtedly  refer- 
able to  pathogenic  micro-organisms,  and  although  a  great  deal  of  careful 
investigation  has  been  devoted  to  the  subject,  we  are  still  in  the  dark  as 
to  its  precise  nature.  Not  one  of  the  many  micro-organisms  brought 
forward  up  to  the  present  time  has  gained  complete  recognition.  In 
this  respect  the  producer  of  typhus  fever  closely  resembles  that  of  the 
acute  exanthemata,  which,  as  will  be  shown  more  and  more  clearly  in 
these  pages,  exhibit  a  very  close  similarity  to  typhus  fever,  both  in 
their  etiology  and  in  their  clinical  features.  Their  exciting  causes,  like 
the  cause  of  typhus  fever,  have  obstinately  resisted  our  present  methods 
of  bacteriologic  research,  and  they  accordingly  form  a  special  group 
among  the  acute  infectious  diseases,  the  etiology  of  which  appears  to 
require  some  entirely  new  and  hitherto  unknown  methods  of  inves- 
tigation. 

The  theory  of  the  chemic  nature  of  the  poison  of  typhus  fever  is  at  the 
present  time  interesting  for  historic  reasons  only.  Curiously  enough,  the 
supporters  of  the  theory  of  a  gaseous,  ammoniacal   nature  of  the  "  typhus 


ETIOLOGY.  483 

coutagium "  (Liebig  and  others)  sought  their  strongest  argument  in  the 
peculiar  mode  of  origin  and  spread  of  the  disease.  Much  interest  attaches 
to  a  chapter  iu  Griessinger's  classic  work,  which  stands  as  an  example  of 
incisive  scientific  reasoning,  in  which,  after  a  careful  analysis  of  all  the 
etiologic  factors,  he  refutes  the  theory  of  the  gaseous  nature  of  the  couta- 
gium and  declares  it — the  contagium — to  be  corpuscular  and  dust-like  in 
character. 

In  regard  to  the  various  theories  advanced  as  to  the  microparasitic 
nature  of  the  typhus  contagium,  we  shall  pass  over  the  isolated  experiments 
of  the  first  investigators  and  restrict  ourselves  to  the  more  important  of  the 
newer  contributions,  which  even  the  authors  themselves  do  not  always  con- 
sider quite  convincing. 

In  1888  Moreau  and  Cochez '  described  a  bacillus  resembling  the  Eberth 
bacillus,  which  they  isolated  from  the  blood  and  urine  of  patients  and  which 
they  regarded  as  the  probable  cause  of  typhus  fever. 

A  year  later  Hlava's  ^  work  on  the  poison  of  typhus  fever,  based  on 
material  obtained  from  the  Prague  epidemic  of  1888,  aroused  great  interest 
among  medical  men.  Hlava  examined  45  cadavers  and  obtained  from 
about  two-thirds  of  them  a  peculiar  streptobacillus,  which  he  was  able  to 
find  in  the  living  subject  also,  although,  it  is  true,  not  with  the  same  con- 
stancy. The  micro-organism  was  found  only  in  the  blood  and  could  not  be 
isolated  from  the  organs.  Hlava  himself  is  very  guarded  in  his  statements 
as  to  the  specificity  of  his  micro-organism,  and  soon  afterward  it  was  dis- 
puted by  other  investigators  (Cornil,  Babes,  and  others). 

In  1892  an  important  paper  was  published  by  Lewaschew,'  who  found 
minute,  very  refractive,  coccus-like  corpuscles  in  the  blood  of  typhus  patients, 
especially  in  that  derived  from  the  spleen.  These  were  found  in  fewer 
numbers  in  other  portions  of  the  circulation — for  instance,  in  blood  taken 
from  the  tip  of  the  finger.  Some  of  these  corpuscles  were  provided  with 
flagella  that  could  be  stained  by  Loffler's  method,  like  the  flagella  of  the 
Eberth  bacillus.  He  also  found  free  flagella  without  any  apparent  connec- 
tion with  cocci.  These  Spirochetae  exanthematica,  as  he  called  them,  Lewas- 
chew  regarded  as  various  forms  belonging  to  the  same  organism  and  indi- 
cating diflPerent  stages  of  their  life-history  and  development,  and  he  was 
strongly  inclined  to  accept  them  as  the  cause  of  typhus  fever. 

Soon  afterward  Thoinot  and  Calmette*  declared  that  Hlava's  micro- 
organism was  only  a  secondary  phenomenon  without  any  etiologic  signifi- 
cance, and  brought  forward  a  new  cause  of  the  disease.  This  they  described 
as  a  flagellate,  and  in  some  cases  ameboid,  organism,  which  they  claim  to 
have  found  in  the  splenic  blood  of  5  living  subjects,  and  iu  1  case  from  the 
pulmonary  blood  after  death. 

Dubief  and  Briihl  ^  described  a  small  diplococcus  provided  with  a  cap- 
sule, which  they  claimed  to  have  found  in  the  blood,  but  especially  in  the 

1  "  Contribut.  a  I'etude  du  typh.  exanth.,"  Gaz.  hebd.,  1888,  No.  28. 

2  "Etude  sur  le  typh.  exanth.,"  Arch.  Boheme  de  med.,  1889,  T.  iii.,  1,  and 
Centralbl.  f.   Bakt,  1890. 

3  "Ueber  die  Mikro-organismen  des  Flecktyphus,"  DmtscJi.  med.  Woch.,  1892, 
No.  13.      "  Ueber  die  Mikroparasiten  des  Flecktyphus,"  Ibid.,  No.  34. 

*  ' '  Notes  sur  quelqucs  exainens  de  sang  dans  le  typh.  exanth. , ' '  Annales  de  Vhistitut 
Pasteur^  1892,  and  Tj-aite  de  med.,  by  Charcot,  Bouchard  et  Brissaus,  T.  ii.,  p.  9. 

5  '' Contribution  a  I'etude  anatomo-pathologique  et  bakteriologique  du  typh. 
exanth.,"  Arch,  denied.  Exjoa'im.,  1894. 


484  TYPHUS  FEVER. 

air-passages,  in  pulmonary  foci,  and  in  the  sputum.  These  thev  said  could 
easily  be  recognized  when  staineil  with  methylene-blue.  The  micro-organ- 
isms were  grown  on  various  nutritive  media,  as  agar,  and  vielded  orange- 
yellow  cultures.  The  authors  also  lielieve  that  they  were  able,  by  experi- 
mental inoculation  of  animals,  to  protiuce  a  condition  resembling  typhus 
fever. 

Finally,  it  may  be  added  that  ]\Iott'  long  ago  described  a  variety  of 
motile  spirilla  resemiding  Lewaschew's  organisms  in  the  blood  of  tvphus 
fever  patients,  and,  further,  that  Cheeseman  claims  to  have  discovered  small 
non-motile  bacilli  with  rounded  extremities,  occurring  either  in  pairs  or  in 
short  chains,  which  he  says  he  was  able  to  cultivate  on  blood-serum  but  not 
on  gelatin,  and  which  he  called  the  Bacillus  sanguinis  typhi  exanthematici. 
We  thus  have  a  veritable  sample-card  of  bacteriologic  findings,  and  it  will 
be  best  for  the  present  to  reserve  judgment.  Quite  recently,  in  fact,  men 
(McOxney)  have  come  forward  declaring  that  the  blood  of  typhus  fever 
patients  is  free  from  specific  micro-organisms.  Kelsch's  theory,  that  the  cause 
of  typhus  fever  is  a  micro-organism  that  is  usually  innocuous  and  becomes 
pathogenic  only  under  special  conditions,  has  already  been  referred  to. 

Nature,  Persistence,  and  Mode  of  Dissemination  of  the 
Contagium. — It  follows  logically,  from  our  ignorance  of  the  precise 
nature  of  the  causa  morb'i,  that  we  are  unable  to  say  how  and  where  it 
is  produced  in  the  body  and  w^hat  organs  and  tissues  are  particularly 
affected.  For  similar  reasons  the  question  as  to  the  manner  in  which 
the  poison  leaves  the  body  awaits  future  solution. 

Most  observers  of  the  present  day  are  of  the  opinion  that  the  poison 
is  contained  chiefly  in  the  exhalations  of  the  patients — the  expired  air, 
the  exhalations  from  the  skin,  etc. — and  that  it  attaches  itself  to  the 
dust  contained  in  the  surrounding  atmosphere.  Although  the  second 
part  of  this  hypothesis  tallies  with  the  results  of  our  experience,  the 
first  proposition  should  for  the  present  be  accepted  with  great  caution. 

The  recent  finding  of  Eberth  bacilli  in  the  rose-spots  of  typhoid  fever 
(Neumann,  aSTeufeld,  C'urschmann)  strongly  suggests  the  advisability,  in 
future  epidemics,  of  making  similar  examinations  of  the  typhus  fever  rash 
with  our  improved  bacteriologic  methods.  That  the  contagium  is  excreted 
in  the  feces  and  urine,  as  in  other  infectious  diseases,  seems  doubtful  in  the 
case  of  typhus  fever ;  certainly  it  has  never  been  proved. 

It  is  probable  that  for  some  time  before  and  after,  as  well  as  during, 
the  febrile  period  of  typhus  fever  the  contagium  continues  to  reproduce 
itself  in  the  immediate  surroundings  of  the  patient.  During  this  time 
it  undoubtedly  attaches  itself  to  the  dust  in  the  atmosphere,  and  is  very 
easily  transferred  to  inanimate  objects  handled  by,  or  in  the  immediate 
neighborhood  of,  the  patient,  on  which,  under  favorable  circumstances, 
it  maintains  its  virulence  for  some  time.  Among  these  objects  are 
clothing,  undenvear,  bed-clothes,  curtains,  carpets,  upholstered  liu*ni- 
i  Brit.  Med.  Jour.,  Dec,  1883. 


ETIOLOGY.   ■  485 

tare,  and,  in  fact,  all  objects  with  a  rough,  woolly  surface.  The  fact 
that  washcrw<^men,  bedroom  attendants,  and  those  who  are  charged 
with  the  duty  of  disinfecting  the  infected  articles  are  especially  liable 
to  be  attacked  by  the  disease  in  time  of  epidemic  furnishes  a  strong 
proof  of  this,  if  additional  proof  were  needed. 

If  such  objects  are  protected  against  contact  with  air,  particularly 
air  in  motion,  the  contagium  clinging  to  them  may  maintain  its  vitality 
for  many  months,  or  even  longer  under  especially  favorable  circum- 
stances, and  the  disease  may  thus  be  carried  to  distant  localities  where 
it  was  not  prevalent  at  the  time  and  where  it  is  not  endemic.  Such  a 
transmission  of  the  poison  would  furnish  the  most  natural  etiologic 
explanation  of  the  well-known  so-called  spontaneous  epidemics  in  pris- 
ons, on  board  ships,  etc.,  which  formerly  afforded  so  favorite  an  argu- 
ment in  support  of  the  non-specific  origin  of  spotted  fever.  These  facts 
also  readily  explain  how  the  poison  may  linger  in  apartments  inhabited 
by  patients  if  the  disinfection  has  not  been  properly  attended  to,  as 
well  as  in  cabs,  railroad-cars,  and  other  public  conveyances.  It  should 
be  remembered  that  healthy  persons  may,  without  becoming  infected 
themselves,  carry  the  poison  in  their  clothes  or  in  their  hair,  and  in  that 
way  transmit  it  to  individuals  who  are  not  immune.  In  the  interest 
of  the  community  this  fact  should  be  borne  in  mind  by  physicians, 
attendants,  clergymen,  friends  of  patients,  and,  in  fact,  by  all  persons 
who  come  in  contact  with  them  during  times  of  epidemic. 

There  is  a  remarkable  resemblance  in  all  these  conditions  to  those  observed 
in  the  acute  exanthemata — measles,  scarlet  fever,  and  small-pox.  Owing  to 
the  great  development  of  railroad  and  maritime  transportation,  spotted  fever, 
like  the  acute  exanthemata,  has  been  carried  even  to  distances  that  would 
formerly  have  been  considered  impossible  for  this  disease  to  reach. 

In  Hamburg  a  furrier  was  attacked  by  the  disease  ten  days  after  he  had 
received  a  consignment  of  furs  from  an  infected  locality  in  Poland.  He  had 
not  been  absent  from  home  for  months  ;  had  not  come  into  contact  with  any 
one  suffering  from  the  disease ;  and  more  than  a  year  had  elapsed  since  the 
last  sporadic  case  of  spotted  fever  had  occurred  in  Hamburg.  Fortunately, 
the  patient  was  immediately  isolated,  and  he  was  the  only  one  among  his 
immediate  family  and  attendants  who  was  infected.  The  disease  was  traced 
to  the  infected  objects  before  they  had  been  put  on  the  market,  so  that 
they  were  immediately  disinfected  and  the  further  spread  of  the  disease 
prevented. 

Transmission  by  Bodies  Dead  of  Spotted  Fever. — Even 

the  cadavers  of  spotted  fever  patients  may,  under  certain  conditions, 
transmit  the  disease,  although  Murchison  is,  no  doubt,  disposed  to 
exaggerate  this  danger,  because  he  contracted  his  first  attack  of  spotted 
fever  in  the  dissecting-room.     I  do  not  think  that  the  reproduction  of 


486  TYPHUS  FEVER. 

the  poison  in  the  cadaver  is  at  all  probable,  and  I  believe  that  the 
infection  takes  place  in  very  much  the  same  way  as  in  the  case  of 
inanimate  objects  on  which  the  contagium  has  been  deposited.  In  this 
connection  it  seems  to  me  significant  that  the  danger  of  infection  is  dis- 
tinctly more  marked  in  recent  cadavers.  Thus,  while  we  never  had  a 
case  of  spotted  fever  among  the  physicians  or  servants  during  the 
epidemic  in  Moabit,  although  numerous  autopsies  were  made  in  poorly 
ventilated  rooms,  one  of  my  assistants  and  the  dissecting-room  attend- 
ant who  performed  an  autopsy  on  a  cadaver  a  few  iiours  after  death 
contracted  the  disease. 

The  Period  of  Greatest  Danger  of  Infection. — At  what 
period  of  the  disease  is  the  danger  of  infection  greatest  ?  Undoubtedly, 
at  the  beginning  and  at  the  height  of  the  febrile  stage.  During  the 
stage  of  defervescence,  however,  the  danger  of  contagion  is  not  incon- 
siderable. During  convalescence,  when  the  fever  has  disappeared  per- 
manently, there  is  probably  no  reproduction  of  the  poison  within  the 
body,  and  contagion  during  this  time  occurs  only  by  the  transmission  to 
predisposed  persons  of  the  poison  that  has  been  produced  during  the 
active  period  of  the  disease  and  been  deposited  on  surrounding  objects. 

It  is  true  that  Perry  and  certain  others  consider  the  danger  of  con- 
tagion greatest  during  the  period  of  convalescence ;  but  I  think  this  is 
an  error  that  is  due  probably  to  a  mistake  in  estimating  the  period  of 
incubation. 

For  my  part,  I  consider  transmission  possible  during  the  period  of 
incubation,  and  absolutely  certain  during  the  initial  stage.  The  fact 
that  during  the  latter  jieriod  patients  are  able  to  go  about  or  travel  in 
cars  may  explain  many  cases  in  which  the  patients  deny  having  come 
in  contact  with  individuals  affected  with  the  disease. 

In  this  connectiou  I  remember  a  very  instructive  case  that  I  saw  when  a 
student.  This  occurred  in  one  of  my  fellow-students,  who  became  infected 
while  attending  a  clinic  on  a  typhus  fever  patient.  He  was  one  of  three 
students  from  another  department,  who  had  spent  an  hour  in  a  typhus  fever 
patient's  room  at  a  time  when  the  patient  had  as  yet  no  fever,  and  com- 
plained only  of  slight  general  malaise,  depression,  and  pain  in  the  head 
and  back  ;  but  none  of  the  students  had  been  in  the  room  after  that  time. 
On  the  evening  following  their  visit  the  patient  was  seized  with  a  chill,  this 
being  followed  by  the  usual  initial  rise  in  temperature.  Eight  days  later 
one  of  the  three  students  was  taken  with  tyjjhus  fever.  It  was  subsequently 
ascertained  beyond  a  doubt  that  he  had  not  returned  to  the  house  after  that 
first  visit  and  had  not  come  in  contact  with  any  other  patient ;  in  fact,  there 
had  not  been  any  other  case  of  spotted  fever  in  the  town,  all  the  others 
having  been  carefully  isolated  in  the  hospital. 

The  question  whether  or  not  the  danger  of  infection  varies  in   indi- 


ETIOLOGY.  487 

vidual  patients  or  in  certain  forms  of  the  disease  is  very  difficult  to 
decide.  My  own  experience  leads  me  to  believe  that  it  does  not. 
Although  Griessinger  considers  a  severe  case  more  dangerous  than  a 
milder  one,  we  may  venture  to  remind  even  this  experienced  author  that 
it  is  never  possible  to  estimate  with  sufficient  accuracy  the  influence  to 
be  attributed  to  external  favoring  circumstances. 

As  to  the  claim  that  the  severity  of  a  given  case  is  directly  propor- 
tional to  the  severity  of  the  case  from  which  it  is  derived,  I,  for  my 
part,  must  enter  an  objection.  The  intensity  of  the  disease  undoubtedly 
depends  chiefly  on  the  personal  conditions  of  the  individual  attacked. 

How  and  by  what  channels  does  the  contagium  find  entrance  to  the 
body  ?  I  agree  with  the  majority  of  observers  in  believing  that  in  by 
far  the  greatest  number  of  cases  the  poison  that  clings  to  infected 
objects  in  the  immediate  vicinity  of  the  patient  is  carried  through  the 
air  and  enters  the  body  through  the  organs  of  respiration.  Entrance 
of  the  poison  through  the  skin  is  also  conceivable.  The  intestinal  tract, 
which  plays  the  most  prominent  role  in  the  etiology  of  typhoid  fever, 
appears  to  be  of  very  secondary  importance  for  the  entrance  of  the 
typhus  fever  contagium.  A  very  few  authors  (Netter)  still  maintain 
that  direct  contact  with  the  patient  is  necessary  for  the  transmission  of 
the  disease. 

The  question  that  has  often  been  raised  as  to  the  length  of  time 
necessary  to  be  spent  in  the  neighborhood  of  the  patient  or  the 
duration  of  the  contact  with  inanimate  carriers  necessary  to  produce  the 
infection  has  a  purely  theoretic  interest.  Given  the  necessary  concen- 
tration of  the  poison  and  a  fair  degree  of  predisposition  on  the  part 
of  the  individual,  it  appears  certain  that  a  very  short  time — even 
a  few  moments — may  suffice  to  infect  him,  although  it  will  be  found 
difficult  to  procure  reliable  evidence  on  this  point,  especially  during 
an  epidemic. 

I  saw  an  instructive  case  of  this  kind,  occurring  in  a  furniture  manufac- 
turer, who  was  quite  certain  that  he  had  not  come  in  contact  with  any  fever 
patients  nor  with  any  suspicious  objects,  and  among  whose  employes  there 
had  not  been  any  case  of  spotted  fever.  He  had,  however,  interviewed  a 
workman,  who  appeared  to  him  to  be  ailing,  promising  him  employment  after 
he  should  have  recovered  his  health.  The  interview  did  not  last  more  than 
five  minutes,  and  was  held  in  his  private  office,  which  was  very  small  and 
badly  ventilated,  the  windows  being  closed.  Two  days  afterward  the  work- 
man was  seized  with  typhus  fever  and  admitted  to  the  lazaretto  at  Moabit, 
where  he  had  a  typical,  though  mild,  attack  of  the  disease ;  while  the  manu- 
facturer, whom  I  saw  while  acting  as  a  consultant  during  his  illness,  con- 
tracted a  very  severe  form  of  the  disease  on  the  seventh  day  after  his  inter- 
view with  the  workman. 


488  TYPHUS  FEVER. 

Mo!<t  patients  give  a  history  of  Iniving  been  exposed  to  infection 
repeatedly  or  continuously  for  a  long  time.  The  precise  moment  when 
the  j)oison  eifects  an  entrance  into  the  body  is  no  doulit  dependent  on 
accidentid   individual   or  external  conditions. 

In  general  it  may  be  said  tiuit  the  danger  t)f  infection  increases  with 
the  frequency  and  duration  of  exposure  and  with  the  concentration  of 
the  poison.  The  latter  stands  in  direct  ratio  to  the  number  of  patients, 
and  in  indirect  ratio  to  the  size  and  excellence  of  the  ventilating  facilities 
of  the  wards. 

Reaction  of  the  Poison  to  Chemical  and  Physical  Agents. 
— The  poison  appears  to  l)e  constantly  rej)r(»duced  in  the  body  of  the 
patient  during  the  febrile  period,  and  it  umpiestionably  maintains  its 
highest  degree  of  virulence  in  his  immediate  vicinity,  being  intimately 
united  to  dust  and  other  carriers  of  that  kind.  It  does  not  appear  to 
be  easy  to  destroy  the  poison  by  chemical  means.  The  simpler  methods 
of  disinfection  formerly  used,  such  as  spraying  the  room  with  carbolic 
acid  or  chlorin  water,  are  probably  of  very  little  value.  The  newer  dis- 
infectants that  have  recently  been  recommended,  such  as  formalin,  have 
not  as  yet  been  thoroughly  tested.  The  disinfection  of  beds,  linen,  and 
other  objects  used  about  the  patient's  body  with  the  above-named  disin- 
fectants is  quite  inadequate. 

Physical  agents,  on  the  other  hand,  appear  to  be  far  more  destructive 
to  the  poison  than  any  chemical  disinfectants  known  at  the  present  time. 
High  temperatures  especially  are  of  value  in  this  respect.  In  Moabit, 
where  many  experiments  ^vith  dry  heat  were  made,  the  clothes  and  per- 
sonal effects  of  the  patients  were  rendered  absolutely  sterile  by  exposure 
to  a  temperature  of  100°  to  120°  C.  for  one  or  two  hours. 

Of  the  effect  of  cold,  veiy  little  is  known,  although  Hildenbrand 
believes  that  very  low  temperatures  have  a  distinctly  destructive 
influence. 

It  is,  of  course,  well  known  that  epidemics  are  both  more  frequent 
and  greater  in  extent  during  the  winter  than  during  the  summer ;  this 
is  due  to  the  social  conditions  existing  during  the  winter  season. 

It  would  appear  that  the  poison  is  not  carried  a  very  great  distance 
through  the  air.  According  to  my  experience,  it  is  much  less  easily 
transported  than  that  of  variola,  and  possibly  also  than  that  of  other 
acute  exanthemata. 

"While  in  small-pox  epidemics  I  have  often  seen  cases  in  which  the 
poison  was  wafted  across  a  narrow  street  and  carried  to  the  inmates  of  a 
house  on  the  opjwsite  side,  I  have  never  seen  infection  carried  in  this 
way  in  Moabit,  where  we  had  often  to  fill  one  barracks  with  typhus 


PREDISPOSING  CONDITIONS.  489 

patients,  and  the  adjoining  one  with  patients  suffering  from  surgical 
injuries.  It  is  owing  to  this  quality  of  the  contagiuni — that  of  not 
being  easily  carried  to  a  great  distance — that,  when  an  isolated  case  of 
typhus  fever  is  admitted  to  a  hospital  by  mistake  or  want  of  judg- 
ment, the  disease  does  not  spread  beyond  the  patient's  immediate 
neighbors,  providing  the  wards  are  large  and  airy.  The  epidemic 
becomes  general  only  when  the  number  of  typhus  patients  in  the 
wards  increases. 

Ventilation  has  a  marked  influence  on  the  contagium,  the  prophy- 
lactic importance  of  which  cannot  be  too  much  emphasized.  In  large, 
well-ventilated  wards  that  are  not  too  crowded  the  virulence  is  much 
diminished,  especially  if  the  patients  are  kept  in  the  open  air,  or  if  the 
doors  and  windows  are  left  open. 

I  made  some  very  instructive  observations  in  this  respect  in  the  lazaretto 
at  Moabit.  During  the  summer  mouths  I  kept  our  patients  almost  all  day 
in  the  open  air,  which  incidentally  had  a  very  good  therapeutic  effect,  and 
in  winter  the  windows  were  kept  constantly  open,  the  wards  being  kept  well 
heated,  however.  Not  a  single  physician  and  very  few  of  the  attendants  were 
infected  ;  of  the  latter,  only  those  were  infected  w^ho,  contrary  to  ray  orders, 
had  bathed  the  patients  in  the  small,  ill-ventilated  bath-rooms,  instead  of  in 
the  spacious,  well-ventilated  ward. 

So  much  for  the  general  conditions  that  favor  the  origin  and  spread 
of  the  disease.  The  poison  has  always  been  found  most  virulent  when 
large  numbers  of  persons  have  been  crowded  together  in  improperly 
ventilated  and  ill-kept  localities  under  bad  hygienic  conditions.  Prisons, 
badly  planned  barracks,  inns,  and  lodging-houses  of  the  lowest  kind, 
work-houses,  ships,  and  defectively  built  hospitals  are  the  chief  foci  of 
the  disease.  Hence  it  is  that  w^e  have  the  various  synonyms,  lazaretto 
fever,  ship  fever,  prison  fever,  camp  fever,  etc. 


PREDISPOSING  CONDITIONS. 
PERSONAL  CONDITIONS. 

The  predisposition  to  typhus  fever  appears  to  be  universal,  and  is 
very  strongly  developed  in  most  individuals. 

Immtmity. — Very  few  appear  to  be  entirely  unmune  by  birth. 
The  older  authors,  notably  Hildenbrand,  believed  that  the  body  could 
become  accustomed  to  the  poison,  and  in  this  way  a  certain  grade  of 
acquired  immunity  against  the  disease  might  be  developed,  as  among 
attendants,  physicians,  and  priests,  who  frequently  work  among  patients 
during  severe  epidemics.     I  think  this  is  very  doubtful,  and  none  of 


490  TYPHUS  FEVER. 

the  more  recent  authors,  among  whom  I  would  count  myself,  appears 
to  have  had  an}-  favorable  experience  in  this  respect. 

On  the  other  hand,  one  attack  of  the  disciise  confers  an  acquired 
immunity  on  tlie  great  majority  of  persons,  lasting  a  long  time — usually 
for  the  remainder  of  the  individual's  life.  In  this  respect,  also,  typhus 
fever  resembles  the  acute  exanthemata,  especially  scarlet  fever,  measles, 
and  variola.  Whether  the  degree  of  immunity  after  an  attack  of 
typhus  fever  is  as  great  as  it  is  in  these  other  diseases  is  a  question  on 
which  there  is  a  difference  of  opmion  among  the  various  authors. 
Griessinger  and  i\f urchison  report  cases  of  the  same  individual  being 
attacked  more  than  once.  Griessinger  does  not  seem  to  consider  this  a 
very  rare  occurrence,  and  Murchison  acquired  his  experience  from  his 
own  case,  he  having  been  attacked  twice  by  the  disease. 

It  has  been  reported  that  the  same  individual  has  been  attacked 
twice  even  in  the  same  epidemic. 

I  myself,  however,  am  of  the  opinion  that  one  attack  of  typhus 
fever  confers  almost  as  perfect  an  immunity  for  the  remainder  of  the 
individual's  life  as  does  an  attack  of  any  of  the  exanthemata. 

In  consequence  of  such  a  belief,  it  has  long  been  the  custom  everywhere 
in  the  beginning  of  an  epidemic  to  employ  attendants  who  have  already  had 
the  disease.  The  wisdom  of  this  procedure  is  proved  by  Murchison's  experi- 
ence in  the  London  Fever  Hospital.  He  says  that  he  never  saw  an  attend- 
ant attacked  more  than  once. 

Ag"e  and  sex  appear  to  exert  a  very  subordinate  influence  on  the 
susceptibility  to  typhus  fever,  as  is  shown  whenever  the  entire  popula- 
tion of  a  locality  is  exposed  to  the  same  channels  of  infection  under 
identical  external  conditions.  Not  inconsiderable  differences  have,  of 
course,  been  observed,  some  of  which  are  easily  explained,  while  for 
others  the  explanation  has  not  as  yet  been  found. 

In  many  epidemics  the  male  population  is  more  generally  attacked 
than  the  female ;  but  when  the  conditions  are  carefully  examined,  it  is 
found  that  the  males,  owning  to  their  mode  of  life  and  occupation,  are 
more  frequently  and  more  constantly  exposed,  both  to  the  poison  itself 
and  to  the  various  predisposing  factors ;  and  we  accordingly  find  that 
whenever  the  disease  is  carried  into  localities  that  had  before  been  free 
from  infection,  the  cases  are  at  first  almost  exclusively  confined  to  the 
male  population,  but  as  the  disease  develops,  and  in  the  course  of  time 
gradually  extends  to  the  resident  portion  of  the  community,  these  differ- 
ences gradually  disappear.  In  countries  where  the  disease  is  endemic 
and  is  not  brought  in  by  the  floating  population,  it  usually  affects  both 
sexes  equally  from  the  beginning. 


PREDISPOSING  CONDITIONS.  491 

The  best  proofs  of  this  we  find  in  England  and  Ireland,  the  classic  homes 
of  typhus  fever.  In  the  London  Fever  Hospital,  during  fourteen  years, 
3780  men  and  3792  women  were  admitted.  During  the  Irish  epideniic  of 
1817-19  the  number  of  women  was  even  greater  than  that  of  the  men,  32,144 
males  and  34,398  females  being  attacked  by  the  disease. 

If  we  compare  this  with  the  statistics  obtained  in  Guttstat  in  Prussia, 
where  typhus  fever  is  endemic  only  in  a  limited  sense,  and  is  usually  brought 
in  from  neighboring  countries,  we  find  that,  duiing  the  years  from  1881  to 
1885,  among  a  total  of  3928  individuals  attacked  there  were  2905  males 
and  1023  females. 

The  statistics  that  I  obtained  in  Moabit  strikingly  illustrate  what  happens 
when  the  disease  is  not  distinctly  endemic  and  when  stringent  hygienic  pre- 
cautions are  taken  to  prevent  the  floating  population  from  infecting  the 
permanent  residents.  During  the  years  1878  and  1879  we  treated  by  far 
the  greater  number  of  all  cases  of  typhus  fever  that  occurred  in  Berlin,  a 
total  of  520  ;  of  these,  488  were  males  and  only  32  females. 

On  the  other  hand,  we  have  an  interesting  communication  from  Passauer, 
which  proves  that  when  the  sexes  are  equally  exposed  to  infection,  they  are 
equally  susceptible.  He  tells  of  a  wedding  party  that  found  a  typhus 
patient  in  the  house  where  the  wedding  was  held,  and  that  followed  him  to 
the  grave  a  few  days  later.  Of  the  members  of  the  party,  19  were  attacked 
— 8  of  them  women. 

I  myself  have  observed  similar  cases.  I  remember,  during  the 
Berlin  epidemic,  in  one  of  the  meaner  lodging-houses  the  proprietor,  his 
wife,  two  barmaids,  and  a  porter  were  attacked  at  the  very  outset  of  the 
epidemic. 

As  to  the  question  of  the  influence  of  age,  v\^e  must  not  place  much 
reliance  on  mere  numbers,  but  must  take  into  consideration  not  only 
the  variations  in  physical  condition  incident  to  age  itself,  but  also  the 
differences  in  social  condition,  mode  of  life,  occupation,  etc.,  peculiar  to 
the  different  periods  of  life.  If  we  examine  the  reports  based  on  large 
numbers  of  patients  in  extensive  epidemics,  or  the  statistics  of  large 
hospitals  in  typhus  fever  regions,  we  find  that  the  disease  is  not  nearly 
so  much  confined  to  a  certain  period  of  life  as  are  the  other  acute  infec- 
tious diseases,  especially  typhoid  fever.  Every  period  of  life  will  be 
found  represented  among  the  adults,  including  individuals  over  fifty 
years  of  age,  in  whom,  as  is  well  known,  the  predisposition  to  typhoid 
fever  is  diminished.  In  fact,  the  statistics  in  any  large  epidemic  of 
considerable  duration  show  that  the  percentage  of  individuals  attacked 
in  the  later  decades  of  life  is  quite  as  great,  or  even  greater,  than  the 
percentage  of  all  patients  among  the  inhabitants. 

Children  are  quite  as  liable  to  the  disease  as  persons  of  advanced 
age,  although  older  children  appear  to  be  more  susceptible  than  younger 
ones.  Infants  at  the  breast  are  the  least  disposed.  Among  children, 
those  between  the  ages  of  five  and  fourteen  appear  to  be  the  ones 
most  commonly  attacked.     From  the  first  to  the  fifth  year,  just  as  in 


492  TYPHUS  FEVER. 

typhoid  fover,  tlie  susceptibility  is  (liniinishcd,  altlioiiali  it  is  distinctly 
greater  than  in  suckling  iiitaiits.  The  degree  of  liability  of  children  is 
seen  "vvhen  an  epidemic  breaks  out  in  a  locality  where  tiie  disease  has" 
raged  for  some  time  among  the  adult  population,  a  good  many  of  whom 
ari'  immune.  Under  such  circumstances  the  morbidity  auKnig  children, 
which  usually  ranges  between  12  and  IG  per  cent.,  may  increase 
euornu>usly,  as  is  shown  by  the  Doi'pat  epidemic  of  18(36  and  1867. 
In  this  epidemic  Behse  found  that  60  per  cent,  of  those  attacked  were 
children. 

The  fact  that  among  adults  the  prime  of  life  and  most  productive 
period  furnish  imusually  large  numbers  of  cases  is  readily  explained  by 
external  conditions.  It  is  during  this  period  that  a  man  is  most  active 
in  the  struggle  for  existence,  and  is  then,  more  than  at  any  other  time, 
exposed,  both  to  the  danger  of  infection  and  to  predisposing  factors. 

For  a  further  elucidation  of  the  subject  the  following  tables  are  added. 
The  first  table  shows  the  distribution  as  to  age  of  the  440  patients  admitted 
to  the  lazaretto  in  Moabit  in  the  year  1879  : 

Age.  Taticnts  admitted. 

Under  10  3 

10  to  20 40 

20  to  30 182 

30  to  40 105 

40  to  50 68 

50  to  GO 33 

60  to  70 8 

70  to  80 1 

440 

If  we  compare  this  table  with  that  of  an  equal  number  of  typhoid  fever 
cases  similarly  arranged  according  to  age,  we  see  at  once  that  in  ty])hus  the 
latter  periods  of  life  are  more  strongly  represented  :  almost  one-third  of  the 
patients  wei-e  over  forty  years  of  age,  and  41  of  440  patients  were  between 
fifty  and  seventy. 

A  similar  result  is  shown  in  the  following  table  from  the  Guttstat 
statistics : 

Age.  rntients  admitted. 

Under  15  433 

15  to  40 3064 

40  to  60 699 

Over     GO 89 

Not  a.?certained 72 

Murchison's  statistics  of  3456  cases  treated  in  the  London  Fever 
Hospital  possess  an  equally  strong  interest  and  are  particularly  instructive 
because  they  deal  with  a  country  where  typhus  fever  is  endemic. 


PBEDISPOSINO  CONDITIONS.  493 

Age.                                                 Total  number  attacked.  Percentage. 

Under  5  17  0.49 

5  to  10 183  0.29 

10  to  15 803  10.47 

15  to  20 540  15.79 

20  to  25 ...  495  14.32 

25  to  30 343  9.92 

30  to  35 323  9.34 

35  to  40 270  7.81 

40  to  45 292  8.44 

45  to  50 212  6.13 

50  to  55 150  4.34 

55  to  60 100  2.89 

60  to  65  .        88  2.54 

65  to  70 42  1.21 

70  to  75 24  0.69 

75  to  80 6  0.17 

Over  80  2  0.06 

3456 

The  proportion  of  children  attacked  is  illustrated  by  the  following 
figures  collected  by  Grazer  and  Lebert  during  the  Breslau  epidemic  of  1869. 
Of  a  total  of  1873  typhus  fever  patients,  271,  or  14.57  per  cent.,  were 
children,  divided  according  to  age  as  follows  : 

Age.  Number. 

0  to    1  .    , 0 

1  to    5 35 

5  to  10 77 

.  10  to  15 J^ 

271 

The  table  shows  a  marked  rise  in  the  proportion  with  increasing  age, 
and  a  similarity  in  the  proportion  shown  by  the  various  ages  of  childhood  to 
that  in  typhoid  fever — a  similarity  that  disappears  in  the  case  of  adults. 

Again,  suckling  infants  show  a  very  slight  disposition,  as  do  also  children 
under  five  years  of  age.  From  this  period  the  liability  increases  with  each 
year  of  life. 

Certain  physiologic  conditions  among  women,  such  as  pregnancy, 
the  puerperium,  and  lactation,  do  not  appear  to  have  any  particu- 
lar influence  on  the  liability  to  typhus  fever,  nor  do  they  confer  any 
immunity  against  the  disease.  This  is  an  interesting  point  in  the  dif- 
ferential diagnosis  from  typhoid  fever,  against  which  these  conditions 
appear  to  aiford  a  certain  protection.  The  influence  of  the  disease  on 
the  fetus  has  not  as  yet  been  determined. 

General  Conditions. — The  general  bodily  health  and  the 
individual  and  social  conditions  of  life  on  which  it  depends  play 
an  important  role  in  the  etiology.  Opinions  on  this  point  have  not  been 
modified  to  any  extent  by  the  experiences  of  later  years. 

It  is  a  matter  of  general  experience  that  the  liability  to  typhus  fever, 


494  TYPHUS  FEVER. 

in  itself  so  well  marked  and  ^\■ide-spread,  is  increased  by  anything  that 
exhausts  the  individual  autl  lowers  his  bodily  and  mental  tone.  Want 
and  poverty,  hunger  and  worry,  and  other  depressing  circumstances 
huN'e  always  been  the  most  powerful  allies  of  the  disease. 

Such  conditions,  of  course,  include  unhygienic  livhig  and  close 
crowding  in  filthy  and  ill-ventilated  houses,  subjects  that  have  already 
been  sufficiently  discussed.  We  have  seen  what  an  important  part  they 
play  in  maintaining  and  augmenting  the  virulence  of  the  contagium. 
Such  unfavorable  conditions  are  naturally  most  marked  in  times  of 
general  destitution  and  economic  depression,  during  war  and  other  great 
movements  among  the  population. 

In  this  respect  typhus  fever  again  ])resents  a  marked  difference  from 
typhoid  fever,  which  is  ])rone  to  attack  young  and  vigorous  individuals, 
and  has  comparatively  little  direct  connection  with  overcrowding,  insuf- 
ficient ventilation,  and  pollution  of  the  atmosphere. 

A  few  investigators,  especially  in  France,  have  expressed  the  opinion 
that  the  disease  was  not  due  so  much  to  the  mental  and  physical 
exhaustion  induced  by  poverty  and  general  misery  as  to  the  inevitable 
massmg  together  of  large  numbers  in  small,  badly  ventilated  houses, 
and  the   consequent  increjised  danger  of  direct  infection. 

A  glance  at  the  conditions  of  the  better  classes  will,  however,  suffice 
to  refute  this  opinion.  Although  they  \'\\c  amid  better  surroundings 
and  in  more  carefully  ventilated  houses,  it  is  found  that  among  them 
overexertion  and  exhaustion  act  as  distinct  predisposing  factors.  Phy- 
sicians, attendants,  officials,  and  clergymen  are  particularly  likely  to 
acquire  the  disease  by  contact  with  ])atients  when  they  are  weakened  by 
long-continued  labors  during  the  height  of  an  epidemic,  their  vital  forces 
being  exhausted  by  excessive  work,  wony,  and  loss  of  sleep. 

Cases  that  furnish  a  striking  proof  of  this  statement  can  be  found  in 
almost  all  the  epidemics.  I  recall  the  case  of  a  young  physician,  in  his 
thirty-second  year,  of  powerful  build  and  in  prime  condition,  who  worked 
through  a  severe  epidemic  of  typhus  fever  lasting  three  months,  during 
which  time  he  spent  almost  all  day  and  a  good  part  of  the  night  in  ill-ven- 
tilated wards  filled  with  typhus  patients  ;  but,  nevertheless,  he  did  not  con- 
tract the  disease.  Some  time  later,  after  he  had  become  much  weakened 
by  certain  depressing  experiences,  loss  of  sleep,  and  nervous  dyspepsia,  he 
treated  only  a  few  patients  in  well-kept  houses  in  a  lartre  city,  contracted  the 
disease  within  two  weeks,  and  was  brought  to  the  verge  of  the  grave. 

Cases  of  this  kind  illustrate  temporary  variations  in  the  lialiility  of  the 
same  individual,  and  tend  to  show  that  the  liability  to  the  disease  may  sud- 
denly become  very  great  under  certain  conditions. 

On  the  other  hand,  some  facts  can  be  cited  to  show  that  the  suscep- 
tibility to  the  disease  is  diminished  when  the  individual   is   in  perfect 


PREDISPOSING   CONDITIONS.  495 

condition,  although  not  in  the  same  degree  as  it  is  increased  by  depress- 
ing bodily  conditions. 

In  Hamburg  I  have  frequently  seen  patients  who  had  contracted  the 
disease  outside  the  city,  and  who,  before  coming  to  the  hospital,  had  spent 
hours  and  even  days  in  lodgings  situated  in  narrow  streets,  without  trans- 
mitting the  disease  to  any  of  the  native  inhahitauts.  The  only  explanation 
for  this  that  I  can  give  is  that  even  the  poorer  peofjle  in  Hamburg  earn 
comparatively  good  wages,  and  are,  accordingly,  fairly  well  fed,  so  that  their 
bodies  are  generally  in  good  condition. 

It  need  hardly  be  said  that  exhausting-  diseases  have  the  same 
effect  as  what  the  French  call  la  mis^re  physiologique.  Among  conva- 
lescents from  other  acute  infectious  diseases  there  is  unquestionably  a 
greater  disposition  to  contract  the  disease  and  reproduce  the  materia 
morbi.  In  hospitals  where  the  typhus  patients  are  not  sufficiently 
isolated,  patients  convalescing  from  other  diseases  are  found  to  be 
particularly  liable  to  the  disease. 

Chronic  or  Acute  Diseases. — In  the  same  way,  a  still  existing 
chronic  or  subacute  condition  that  has  led  to  a  marked  disturbance  of 
the  nutrition  will  increase  the  liability  to  the  disease.  Individuals  suf- 
fering from  chronic  or  subacute  gastro-intestinal  catarrh  and  nervous 
dyspepsia  appear  to  be  particularly  susceptible.  Experienced  physicians 
tell  us  how,  during  great  epidemics,  individuals  who  up  to  that  time 
appeared  to  be  comparatively  immune,  may  be  attacked  if  they  become 
reduced  by  digestive  disturbances  and  are  then  exposed  to  the  infection. 
Patients  suffering  from  chronic  nervous  diseases,  especially  when  they 
are  anemic  or  emaciated,  also  appear  to  be  very  easily  infected. 

Of  the  influence  of  circulatory  and  renal  diseases,  nothing  appears 
to  be  known,  nor  have  I  any  reliable  observations  to  offer  in  this 
respect. 

The  relation  of  typhus  fever  to  chronic  pulmonary  disease,  especially 
to  tuberculosis,  has  given  rise  to  some  differences  of  opinion.  I  cannot 
understand  how  some  of  the  prominent  older  physicians,  such  as 
Hildenbrand,  can  speak  of  the  relative  immunity  of  such  patients,  and 
I  must  agree  with  Murchison  in  taking  the  opposite  stand.  Among  my 
patients  I  had  a  large  number  whose  apices  were  not  entirely  sound  ; 
and  if  it  is  admitted  that  tuberculosis  not  infrequently  complicates  or 
follows  typhus  fever,  it  cannot  well  be  denied  that  at  least  a  large  pro- 
portion of  these  patients  had  a  latent  tuberculosis  at  the  time  they  were 
infected  with  typhus. 

Chronic  intoxications,  such  as  lead-poisoning,  and  particularly  the 
abuse  of  alcohol,  act  as  distinct  predisposing  factors. 

The  effect  of  the  poison  of  typhus  fever  on  patients  suffering  from 


496  TYPHUS  FEVER. 

other  acute  infectious  disease,  especially  during  the  febrile  stage,  has  not 
as  yet  been  diseussetl  in  the  literature. 

In  regard  to  variola  and  typhoid  fever,  1  think  I  have  adduced 
strong  prot)fs  that  they  oifer  a  niaikod  resistance  to  the  entrance  of  the 
germs  of  other  acute  infectious  diseases,  at  least  during  the  febrile  stage, 
and  that  this  in;muuity  only  diminishes  with  the  beginning  of  defer- 
vescence and  does  not  disappear  until  the  fever  has  entirely  subsided. 
But  Ave  know  nothing  of  the  behavior  of  tyj)hus  fever  in  this  respect, 
except  in  connection  with  recurrent  fever.  Patients  suffering  from  the 
latter  disease  are,  according  to  my  observation,  as  well  as  according  to 
other  authors,  very  susceptible  even  during  the  febrile  stage. 

I  saw  an  iustructive  case  of  this  kind  duriny  the  epidemic  of  1879  in 
the  lazaretto  at  Moabit.  It  was  that  of  a  young  man,  twenty-three  years  of 
age,  in  whose  blood  tlie  spirilla  had  been  found  on  the  last  day  of  the  third 
relapse.  On  the  following  day  the  patient  had  a  severe  chill  and  his  tem- 
perature began  to  rise  ;  the  fever  continued  high,  and  on  the  fourth  day  a 
characteristic  and  very  abundant  typhus  fever  rash  made  its  appearance. 
The  attack  was  mild  and  very  short,  the  fever  having  entirely  disappeared 
on  the  eleventh  day  (see  Fig.   57). 

Needless  to  say,  experiences  such  as  these  do  not  justify  similar 
argimients  in  regard  to  other  infectious  diseases. 

Occupation  and  social  conditions  can  influence  the  liability  to 
typhus  fever  only  in  so  far  as  they  determine  the  ])hysical  predisposing 
factors  that  have  been  referred  to,  or  as  they  involve  an  unusual 
exposure  to  the  infection.  Both  these  conditions  are  present  in  the 
poorer  classes.  Among  the  better  classes  the  question  of  exposure  is, 
of  course,  more  important  than  constitutional  conditions,  which  are 
unfavorable  only  as  the  result  of  accident  or  occupation. 

Some  English  authors  claim  for  special  occupations  a  certain  degree 
of  protection  against  typhus.  They  mention  in  this  resjiect  tanners, 
workers  in  fat,  candlemakers,  and  butchers.  In  attributing  their  rela- 
tive immunity  to  the  fact  that  they  are  more  or  less  constantly  handling 
putrid  material,  Griessinger  unconsciously  inclines  toward  the  miasmatic 
theorv  of  typhus  fever,  which  he  has  himself  elsewhere  refuted. 

For  my  part  I  have  seen  as  many  cases  of  the  disease  among 
butchers  as  among  other  workmen.  It  is  true  that  during  our  epidemic 
the  individuals  belonging  to  this  trade  were  most  of  them  vagabonds. 
But  even  if  it  should  be  found  that  butchers  are  less  liable  than  other 
workmen,  a  fact  which,  as  I  have  said,  I  do  not  consider  proved, 
the  most  natural  explanation  is  that  they  are  unquestionably  better 
nourished. 


PREDISPOSING  CONDITIONS.  497 

SEASON   AND   METEOROLOGIC    CONDITIONS. 

Among  general  etiologic  factors  the  season  and  mcteorologic  condi- 
tions are  to  be  mentioned.  They  exert  very  little  influence  on  typhus 
fever,  which,  therefore,  differs  in  this  respect  from  other  diseases.  In 
fact,  it  would  appear  that  the  development  and  invasion  of  the  inciting 
cause  are  in  no  wise  modified  by  such  external  conditions. 

It  has  been  observed,  however,  that  the  disease  is  more  prevalent 
during  the  colder  season,  most  of  the  epidemics  having  reached  their 
height  in  the  early  months  of  the  year, — that  is,  in  the  latter  half  of 
the  winter  or  the  early  spring, — and  subsided  again  during  the  summer. 
But  this  can  be  explained  in  another  way.  During  the  cold  season  all 
the  factors  influencing  individual  disposition  and  transmission  of  the 
poison,  such  as  want  of  employment,  poverty,  and  overcrowding  in 
badly  ventilated  houses,  are  much  more  active.  With  the  coming  of 
summer  the  poorer  portion  of  the  population  naturally  tends  to  scatter, 
work  becomes  more  plentiful,  and  the  conditions  of  life  are  accordingly 
improved. 

It  has  always  been  observed  in  the  larger  cities,  notably  in  Berlin,  that 
the  disease  rapidly  disappears  among  the  wandering,  houseless  portion  of  the 
inhabitants  as  soon  as  they  begin  to  sleep  in  the  open  air  instead  of  seeking 
the  shelter  of  "  pens  "  and  asylums. 

GENERAL   MANIFESTATIONS   OF   THE   DISEASE. 

Sporadic  Cases. — ;^ndemics  and  epidemics. — The  etiology 
of  typhus  fever  is  in  many  respects  peculiar,  and  this  alone  lends  to  the 
disease  a  distinct  character  of  its  own,  especially  as  regards  its  outbreak 
and  the  manner  of  its  spread.  A  number  of  features  that  distinguish  it 
sharply  from  typhoid  fever  and  give  to  it  a  marked  resemblance  to  the 
acute  exanthemata  could  be  mentioned.  The  development  and  exten- 
sion of  the  disease  depends  chiefly  on  the  followmg  factors  : 

Individual  predisposition,  which  is  practically  the  same  for  both 
sexes  and  all  ages ;  the  immunity  acquired  by  one  attack,  which  ha  the 
case  of  most  individuals  persists  throughout  life ;  the  great  ease  with 
which  the  poison  is  carried  through  the  air ;  its  virulence  and  persist- 
ence whenever  ventilation  is  defective ;  and,  finally,  the  fact  that  the 
disease  is  constantly  present  in  but  few  countries  of  the  earth  and  is 
only  occasionally  carried  to  others. 

This  explains  why  in  countries  where  typhus  fever  is  endemic,  and 
the  population  is  practically  saturated  with  the  poison  of  the  disease,  it 
is  only  relatively  endemic  or  sporadic,  becoming  distinctly  epidemic 
only  when  a  large  number  of  predisposed  individuals  have  had  tmie  to 

32 


498  TYPHUS  FEVER. 

collect.     It  never  fails  to  assume  alarming  proportions  when  it  is  carried 

to  a  region  where  it  i.s  not  endemic  and  where  the  entire  population 
is  accordingly  predi.sposetl  to  it ;  or  when,  on  the  other  hand,  large 
numbers  of  predisposed  individuals  come  into  countries  where  the 
poison  is  constantly  present,  as  occurs  in  time  of  war  or  in  great 
migratory  movements. 

That  the  presence  of  tlie  poison  is  an  absolutely  essential  factor 
under  such  circumstances  was  shown  by  the  Franco-Prussian  war. 
Although  the  world  has  never  seen  the  mobilization  of  greater  masses 
of  men  than  occurred  at  that  time,  typhus  fever  did  not  develop,  while 
typhoid  fever  and  dysentery,  which  have  an  entirely  different  etiology, 
claimed  innumerable  victims.  The  wide  distribution  of  typhoid  fever 
is  one  of  its  chief  points  of  distinction  from  typhus  fever.  Thus,  while 
typhoid  fever  occurs  sporadically,  or,  at  least,  among  a  relatively  small 
nmnber  of  patients,  and  becomes  epidemic  only  when  the  amount  of  the 
infective  material  is  accidentidly  increased  in  rivers  and  water-systems, 
typhus  fever  is  scarcely  ever  confined  to  single  cases  or  house  epidemics, 
and  then  only  under  special  circumstances.  It  regularly  assumes  the 
form  of  a  tremendous  epidemic  whenever  the  contagiimi  invades  a  popu- 
lation that  is  not  protected  by  constant  exposure  and  that  lives  amid 
bad  social  and  hygienic  conditions. 

Hpitotne. — Our  discussion  of  the  etiology  may  be  epitomized  in 
the  following  conclusions  : 

Although  the  cause  of  typhus  fever  has  not  as  yet  been  determined, 
it  is  cei'tain  that  the  disease  does  not  arise  spontaneously,  and  that  its 
development  and  distribution  depend  on  the  action  of  a  specific  cause 
that  is  produced  only  in  the  body  of  an  individual  affected  with  the 
disease,  and  that  is  transmitted  by  him  either  directly  or  indirectly  to 
other  predisposed  individuals. 

The  disposition  to  the  disease  is  universal.  Other  things  being 
equal,  all  ages,  excepting  infancy,  and  both  sexes  are  equally  attacked. 

The  condition  of  the  individual,  especially  a  depraved  state  of  nutri- 
tion and  loss  of  vital  energy  due  to  the  effects  of  poverty,  hunger,  and 
disease,  exerts  an  enormous  influence  on  the  disjiosition.  Tyjihus  fever 
is  the  disease  of  poverty-stricken  and  suffering  luunauity,  and  it  always 
follows  in  the  wake  of  war  and  misery. 

The  great  majority  of  individuals  acquire  immunity  by  one  attack 
of  the  disease. 

The  way  in  which  the  germs  leave  tlie  body  of  the  individual  in 
wliom  they  are  jiroduced,  and  the  port  of  entry  by  which  they  gain 
access  to  the  body,  are  not  known  ;  it  is  probable  that  the  respiratory 


PREDISPOSING   CONDTriONS.  499 

organs  and  the  external  skin  play  the  most  important  role  in  tliis 
respect. 

The  germs  of  the  disease  are  most  [)lentif"iil  in  tiie  immediate  neigh- 
borhood of  the  patient,  and  they  are  carried  by  dust. 

Tliey  attach  themselves  with  great  tenacity  to  the  various  objects 
that  come  into  direct  contact  with  the  patient  or  that  have  been  ex[>(js(;d 
to  the  surrounding  air.  In  this  way  the  disease  may  remain  dormant 
for  a  long  period  of  time  and  may  be  carried  to  distant  places  entirely 
free  from  the  disease,  circumstances  that  lend  color  to  the  former  theoiy 
of  spontaneous  development. 

Plenty  of  fresh  air  and  good  ventilation  exert  an  undoubted  influ- 
ence in  restricting  the  spread  of  the  disease.  Conversely,  also,  the 
vitality  of  the  germs  increases  in  direct  proportion  to  overcrowding  and 
inadequate  ventilation. 

The  germs  do  not  appear  to  be  carried  by  liquid  media,  least  of  all  by 
water ;  nor  do  they  appear  to  reside  in  the  soil  or  to  have  any  especial 
relations  with  it,  as  was  formerly  erroneously  believed  of  typhoid  germs. 

The  sum  total  of  etiologic  factors  easily  explains  the  great  ease  with 
which  the  disease  spreads  and  its  peculiar  tendency  to  appear  in  ejji- 
demics.  It  also  explains  why  the  disease,  when  imported  into  regions 
where  it  is  not  epidemic,  first  attacks  the  poorer  portions  of  the  popula- 
tion and  spends  its  greatest  force  among  them,  and,  if  it  spreads  to 
the  better  classes  at  all,  does  so  only  in  severe  epidemics  and  when  the 
disease  is  at  its  highest. 


PATHOLOGY. 

GENERAL    FEATURES. 

THE  STAGE   OF   INCUBATION. 

Like  the  other  acute  infectious  diseases,  typhus  fever  has  a  stage  of 
incubatiou — that  is  to  say,  a  period  interveninji;  between  the  effective 
inoculation  of  the  patient  and  the  true  beginnmg  of  the  disease. 

In  the  great  majority  of  cases  the  patients  are  entirely  free  from 
symptoms  during  this  period.  Only  occasionally  do  they  complain  of 
indefinite  symptoms,  such  as  headache,  vertigo,  pain  in  the  back,  loss 
of  appetite,  fatigue,  or  depression.  In  a  few  instances  coryza  and  con- 
junctival catarrh  have  been  noticed.  In  the  case  of  two  individuals 
wdio  became  infected  in  the  hospital,  under  my  personal  observation, 
there  was  veiy  slight  fever,  with  practically  normal  daily  variations. 

The  length  of  the  period  of  incubation  varies,  owing  to  some  causes 
not  as  yet  very  well  known.  I  agree  with  most  authors  in  considering 
the  usual  duration  to  be  from  eight  to  twelve,  at  most  fourteen,  days  ; 
but  a  duration  of  from  four  to  seven  days  has  repeatedly  been  observed. 
On  the  other  hand,  an  incubation  stage  of  three  weeks'  duration  should 
always  be  regarded  with  suspicion. 

A  few  cases  have  been  reported  in  the  literature  by  reliable  authors 
(Murchison,  Gerhard),  in  which  the  incubation  was  said  to  have  lasted  only 
a  day  or  but  a  few  hours.  The  shortest  period  in  my  experience  was  four 
days.  This  was  in  a  man,  forty  years  of  age,  coming  from  a  locality  abso- 
lutely above  suspicion,  who  had  taken  part  in  certain  festivities  at  a  public 
house  where  he  had  been  a  stranger.  Four  days  later  he  was  attacked  by 
the  first  manifestation  of  the  disease.  Immediately  after  the  festivities 
referred  to,  the  innkeeper,  his  wife,  one  child,  and  several  regular  patrons  of 
the  place  developed  typhus  fever  and  were  admitted  to  the  lazaretto. 

The  statements  of  some  of  the  older  writers  (Hayarth,  Barallier  and 
Cheyne,  Bankroft)  in  regard  to  cases  in  which  the  incubation  period  lasted 
from  one  and  a  half  to  six  months  are  due  unquestionably  to  errors  of 
observation  or  diagnosis. 

THE   SUBSEQUENT    COURSE    OF    THE    DISEASE. 

The  subsequent  course  of  the  disease  may  best  be  described  by 
giving  the  history  of  a  severe,  well-developed  case  in  a  healthy  adult, 
ending  in  recoveiy. 

Unlike  typhoid  fever,  but  similar  to  the  acute  exanthemata,  spotted 
fever  presents  a  remarkable  uniformity  in  its  chief  manifestations,  in  its 

600 


PATiiOLoar.  501 

duration,  and  in  the  course  and  mode  of  its  termination.  In  all  largo 
epidemics  not  markedly  modified  by  external  conditions,  especially  social 
ones,  the  characteristic  picture  is  the  same  in  its  main  features.  A  com- 
parison of  the  disease  as  we  know  it  to-day  with  the  descriptions  of 
older  authors  shows  that  it  has  not  changed  in  any  essential  particular 
in  the  course  of  time. 

The  onset  of  the  disease  is  almost  always  abrupt.  The  fever  is 
ushered  in  by  one  or  two  distinct  chills,  or,  more  rarely,  by  chilly 
sensations  lasting  for  several  hours  or  an  entire  day.  This  in  most 
cases  ends  the  true  initial  stage  of  the  disease.  In  consequence  of  the 
sudden,  violent  onset  and  the  rapid  rise  of  temperature  with  chills,  the 
•patients  are  very  much  prostrated  from  the  outset.  Most  of  them  are 
quite  unable  to  work,  and  take  to  their  beds  on  the  first  day ;  while 
even  those  who  possess  a  great  resistance  usually  give  up  on  the 
second  or  third  day  ;  consequently,  medical  treatment  is  sought  much 
earlier  than  is  usually  the  case  in   typhoid  fever. 

The  chill  is  either  accompanied  or  followed  immediately  by  nausea, 
vomiting,  a  sense  of  pressure  in  the  epigastrium,  and  pain  in  the  back, 
the  patient  from  the  very  beginning  lying  passively  in  bed  in  the  dorsal 
position.  The  face  is  feverish  and  red,  presenting  a  peculiar  edema ; 
the  conjunctivae  are  usually  very  much  congested,  and  secrete  copiously. 
The  mucous  membrane  of  the  nose  and  palate  in  many  cases  becomes 
boggy  and  reddened  as  early  as  the  evening  of  the  first  day,  and  the 
patients  complain  of  a  feeling  of  dryness  and  scratching  in  the  throat, 
or  even  of  marked  dysphagia.  While  the  mind  is  usually  clear  except 
for  a  slight  depression  and  apathy  during  the  daytime,  marked  disturb- 
ances of  the  sensorium  begin  to  show  themselves  toward  evening  or 
during  the  night.  The  patients  begin  to  lose  interest  in  their  surround- 
ings, easily  drop  the  thread  of  a  conversation,  and,  if  left  alone,  have 
disturbing  dreams  and  talk  in  their  sleep. 

After  the  chills  and  the  nausea  and  vomiting  have  subsided  the 
fever  rapidly  rises,  and  a  dull,  throbbing,  sometimes  violent  and 
stabbing  headache,  vertigo,  and  tinnitus  aurium  become  prominent 
symptoms.  Some  individuals  suffer  from  violent  pain  in  the  sacral 
region  and  cannot  rest  easily  in  any  position,  while  others  complain  of 
tearing  and  dragging  pains  along  the  large  nerve-trunks,  especially  in 
the  legs,  or  of  hyperesthesia  in  the  finger-tips,  toes,  and  soles  of  the 
feet.     Pain  in  the  joints  is  rarely  present. 

The  tongue  is  tremulous  and  dry,  and  before  the  end  of  the  first 
twenty-four  to  thirty-six  hours  it  has  become  covered  with  a  dirty, 
yellowish-brown  exudate.     The  dryness  of  the  other  mucous  membranes 


502  TYPHUS  FEVER. 

bet'tmics  more  marked,  the  swelling  o^  the  pharynx  and  tonsils  inercases, 
and  the  patients  complain  bitterly  of  a  raging  thirst. 

The  appetite  is  altogether  lost.  The  abdomen  is  neither  swollen  nor 
painfnl,  excepting  in  the  epigastric  region,  which  in  many  patients  is 
veiy  sensitive  to  the  touch.  In  the  beginning  and  during  the  entire  first 
\\eek  the  bowels  are  usually  constipated ;  rarely  there  is  diarrhea.  The 
spleen,  even  at  tins  period,  is  found  by  percussion  and  palpation  to  be 
distinctly  enlarged,  a  feature  that  is  characteristic  of  the  disease  and 
forms  a  usefid  diagnostic  point  in  the  differentiation  from  typhoid  fever. 

The  prostration  increases  so  rapidly  that  most  patients  are  barely  able 
to  sit  up  during  the  first  days  of  the  first  week  ;  but,  notwithstanding 
their  lassitude,  they  toss  about  restlessly  in  bed,  unable  day  or  night  to 
obtain  refreshing  sleep. 

The  fever-curve  differs  from  that  of  typhoid  fever  in  that  it  rises 
rapidly  on  the  first  few  days,  reaching  a  considerable  height  and 
exhibiting  slight  daily  variations,  which  do  not,  as  a  rule,  exceed  half  a 
degree.  It  partakes  of  the  character  of  a  continued  fever,  or,  more 
rarely,  of  a  continued  remittent  fever,  and  early  attains  an  evening 
temperature  of  40°  C,  although  in  severe  cases  and  irritable  indi- 
viduals it  may  reach  from  40.5°  to  41°.  The  temperature  rarely  falls 
below  39°  in  the  morning. 

With  the  rapid  rise  of  temperature  there  is  a  corresponding  rapid, 
uninterrupted  rise  in  the  frequency  of  the  pulse.  Even  in  vigorous 
men  the  pulse  usually  reaches  100  on  the  forenoon  of  the  second  day, 
and  in  the  evening  hours  it  rises  to  110  or  120,  while  women  and 
children  show  an  even  greater  excitability  in  this  respect.  I  have  never 
seen,  in  the  beginning  of  typhus  fever,  the  disproportion  between  the 
pulse-rate  and  the  temperature  that  is  so  valuable  a  diagnostic  feature 
of  typhoid  fever,  and  that  is  so  frequently  observed  in  young  men  with 
typhoid. 

The  arteries  in  the  beginning  are  soft  and  the  pulse  is  normal  in 
volume  and  tension.  The  dicrotism,  characteristic  of  typhoid  fever,  is 
absent  during  the  first  days,  and  sometimes  later,  in  by  far  the  greater 
number  of  cases. 

While  the  fever  and  other  general  disturbances  are  undergoing 
a  rapid  and  uninterrupted  rise,  there  appears,  between  the  third  and 
the  fifth  day,  or  occasionally  before  that  time,  a  phenomenon  that  is 
most  characterLstic  of  the  disease  and  often  determines  the  chagnosis. 
This  is  the  roseolous  eruption.  It  appears  at  first  in  the  form  of  pale- 
red,  hyperemic  patches,  varying  in  size  from  that  of  a  pin-head  to  that 
of  a  lentil,  circular  or  oblong  in  shape,  and  having  ill-defined  edges. 


PATHOLOGY.  503 

* 

When  the  rash  develops  uniformly,  the  patches  appear  first  on  the 
lower  abdomen  and  on  the  chest  and  shoulders.  Thenc<!  they  spread 
at  once  over  the  back  and  extremities  down  U)  the  dorsal  surfaces 
of  the  hands  and  feet  with  such  rapidity  that  the  ultimate  number 
of  the  patches  is  usually  reached  within  from  forty-eight  tf>  seventy-two 
hours.  The  palms  of  the  hands  and  soles  of  the  feet  almost  always 
escape,  and  by  far  in  the  greater  number  of  cases  the  face  as  well,  the 
last  being  simply  very  much  reddened  and  swollen,  and  often  assuming 
an  absolutely  uncanny  expression  on  account  of  the  reddening  and  hem- 
orrhagic injection  of  the  conjunctivae. 

Simultaneously  with  the  eruption  of  the  roseola,  or,  in  irritable  indi- 
viduals, before  it,  a  measle-like  rash  makes  its  appearance,  affecting 
with  predilection  the  extensor  surfaces  of  the  forearms,  the  legs,  chest, 
and  abdomen.  This  fades  before  the  disappearance  of  the  typical 
eruption  and  leaves  no  trace. 

During  this  period  of  the  disease,  which  is  often  designated  the 
stadium  exanthematicum,  many  patients  present  marked  disturbances 
of  consciousness,  even  during  the  daytime.  Their  movements  become 
more  abrupt,  and  they  lose  all  interest  in  their  surroundings.  At  first 
loud  in  their  complaints,  they  become  more  and  more  subdued,  and  cease 
to  complain  of  vertigo,  headache,  or  backache. 

The  tongue  now  becomes  covered  with  scales  and  is  marked  with 
fissures  that  bleed  easily.  If,  as  happens  in  some  cases,  the  coating- 
separates,  the  tongue  appears  unusually  thin  and  pointed,  and  its  sur- 
face shines  as  if  it  were  lacquered.  Meanwhile  the  catarrhal  symptoms 
in  the  pharyngeal  structures  and  in  the  larynx  have  increased.  There 
is  hoarseness  or  even  aphonia ;  the  presence  of  a  short,  dry  cough  shows 
that  the  bronchi  are  also  involved.  This  is  confirmed  by  auscultation, 
which  reveals  crepitant  and  subcrepitant  rales  over  the  entire  extent  of 
the  lungs. 

The  complete  development  of  the  eruption  usually  marks  the  zenith 
of  the  disease.  The  fever  by  this  time  has  reached  its  height  and 
remains  stationary  for  a  varying  period  of  time,  the  temperature-curve 
usually  presenting  the  character  of  a  continued  remittent  fever.  The 
apathy  and  somnolence  that  marked  the  beginning  of  the  disease  are 
now  often  replaced  by  violent  excitement.  The  patient  is  quite  uncon- 
scious, and  finds  no  rest  by  night  or  by  day.  Some  talk,  work,  or 
gesticulate  in  their  dreams,  either  reviewing  former  periods  of  their 
lives  or  imitating  their  visual  occupations.  Others  become  violently 
excited  by  visual  or  aural  hallucinations.  They  imagine  they  are  being 
pursued  and  threatened  with  personal  violence ;  they  cry  out  and  defend 


504  TYPHUS  FEVER. 

themselves  ;  they  jump  out  of  bed  ami  try  to  escape  from  their  tortures  by 
flight  or  by  attacking  their  attendants.  Typhus-  fever  patients  in  this 
stage  of  the  disease  are  incomparably  more  difficult  to  manage  than  any 
others,  and  the  work  in  a  well-tilled  ward  is  about  as  excitmg  and 
exhausting  an  experience  as  doctors  or  nurses  are  likely  to  meet  with  in 
the  exercise  of  their  profession. 

During  this  time — usually  on  the  second  or  third  day  after  its 
a})peai-ance — the  roseola  eruption,  which  was  at  first  a  pure  hyperemia, 
undergoes  a  peculiar  transformation.  A  certain  proportion  of  the 
spots,  varying  in  number  in  different  cases,  assume  a  petechial  type, 
small  hemorrhages  appearing  in  the  center  of  the  patches  or  spreading  to 
the  periphery  and  eventually  occupying  the  entire  site  of  the  eruption. 
The  roseola^,  which  at  first  were  pale  and  indistinct,  now  become 
more  proninmced.  They  become  copper-colored,  with  livid  centers,  or 
the  entire  spot  may  assume  a  dirty,  bluish-red  ajjpearance.  In  the 
severest  type  of  the  disease  most  of  the  lesions  undergo  this  transforma- 
tion ;  and  when,  in  addition,  cutaneous  or  extensive  subcutaneous  hem- 
orrhages make  their  appearance,  the  skin  may  assume  a  many-colored 
dusky  appearance  that  is  positively  terrifying. 

During  the  first  half  of  the  second  week — sometimes  a  little  earlier, 
sometimes  a  little  later — the  clinical  picture,  as  a  whole,  has  usually 
reached  its  highest  development.  The  patients  are  at  this  time  extremely 
weak  and  prostrated,  absolutely  apathetic,  and  cut  off  from  the  external 
world.  The  hearing  is  practically  lost,  the  speech  is  mumbling  and 
unintelligible,  and  the  eyes  are  staring ;  with  mouth  wide  open  and 
hanging,  tremulous  jaw,  the  patient  lies  in  bed  picking  at  the  bed- 
clothes, with  subsultus  tendinum  and  carphology. 

The  wild  gestures  and  the  shouting,  tossing,  and  struggling  cease, 
and  in  their  place  we  have  a  condition  of  stupor,  or,  in  extreme  cases,  a 
true  coma-vigil.  All  desire  for  food  or  drink  is  gone,  swallowing  is 
difficult,  and  the  urine  and  feces  are  discharged  involuntarily.  At  this 
time  there  is  frequently  diarrhea. 

Meanwhile  the  fever  still  continues  at  its  original  height.  The 
pulse  is  more  frequent  and  much  smaller  and  weaker  ;  occasionally  it 
may  be  intermittent  and  irregular.  As  a  result  of  the  long  continuance 
of  the  hyperpyrexia  and  the  further  extension  of  the  bronchitis,  the  res- 
pirations are  accelerated,  superficial,  and  labored.  In  grave  cases  an 
examination  of  the  chest  at  this  time  will  show  either  a  simple  hypostatic 
condition,  a  lobular  pneumonia,  or  an  extensive  inflammatoiy  hypostatic 
consolidation  of  one  or  both  lower  lobes. 

Taken  all  together,  the  clinical  picture  is  worse  than  anything  that 


PATHOLOGY.  505 

can  be  imagined  in  acute  infectious  diseases.  But  recovery  is  jxjssible, 
even  when  the  disease  has  readied  this  extreme  stage.  Fortunately  for 
the  patients,  it  is  a  sharply  self-limited  affection  that  runs  a  certain 
course  and  from  which  recovery  is  possible  even  in  the  severest  cases, 
providing  the  physician  can  manage  to  sustain  his  patient  during  the 
few  days  that  must  elapse  between  the  time  of  severest  intoxication  and 
the  crisis. 

In  moderately  severe  cases,  and  in  severe,  uncomplicated  cases  ending 
in  recovery,  the  fever  usually  begins  to  fall  between  the  tenth  and 
the  twelfth  day  of  the  disease.  It  may  continue  to  the  fourteenth  day, 
but  it  rarely  lasts  longer  than  this.  With  the  fall  of  temperature  most 
of  the  other  symptoms  begin  to  subside.  The  temperature-curve  up  to 
this  time  maintains  the  character  of  a  continued  remittent  fever.  In  a 
few  cases  there  may  occur,  one  or  two  days  before  the  crisis,  a  so-called 
pertubatio  critica,  or  very  marked  variation  in  the  temperature,  the 
nature  of  which  will  be  discussed  in  detail  in  another  place. 

In  the  great  majority  of  cases  the  fever  falls  by  lysis,  with  a  step- 
like curve,  rather  than  by  crisis,  with  a  rapid,  continuous  defervescence. 
In  other  cases,  however,  the  fall  is  so  abrupt  that  the  normal  tempera- 
ture is  reached  within  forty-eight  hours,  or  at  most  after  three  days. 
A  defervescence  lasting  five  days  and  over,  with  marked  intermission  or 
irregularity  in  the  curve,  is  comparatively  rare,  and  should  suggest  a 
careful  examination  for  possible  complications. 

The  beginning  of  defervescence  is  marked  by  an  improvement  in  the 
pulse.  At  first  soft,  small,  and  of  low  tension,  it  decreases  in  frequency, 
as  a  rule,  in  direct  proportion  to  the  fall  of  the  temperature,  so  that 
during  the  first  afebrile  days  it  registers  between  80  and  100,  but  does 
not  fall  quite  to  the  physiologic  rate. 

The  return  to  the  normal  frequency  is  gradual.  As  late  as  the 
fourteenth  day,  or  even  later  in  very  severe  cases,  there  may  be  marked 
variations  in  the  pulse-rate  after  the  slightest  physical  or  mental  dis- 
turbance, which,  under  normal  conditions,  would  have  no  effect.  As  in 
other  acute  infectious  diseases,  the  period  of  defervescence  is  frequently 
followed  by  bradycardia,  which  may  last  for  from  several  days  to  a 
week,  the  exact  nature  and  cause  of  which  have  not  been  satisfactorily 
explained. 

The  enlargement  of  the  spleen,  which  is  not  present  m  all  cases, 
even  in  the  beginning,  subsides  with  the  commencement  of  the  second 
week,  when  it  can  no  longer  be  determined  by  palpation.  A  persistence 
of  the  enlargement  until  the  period  of  defervescence  is  so  rare  that  it 


506  TYPHUS  FEVER. 

suggests  the  presence  of  complications  or  of  a  splenic  tumor  due  to 
some  cause  existing  before  the  onset  of  tyi)lius  fever. 

The  characteristic  sldn-lesious  subside  after  the  disease  has  reached 
its  highest  point,  and,  with  the  exception  of  those  patclics  that  have 
imdergone  petechial  change,  do  not  persist  until  the  period  of  deferves- 
cence. The  petechial  lesions  usually  undergo  branny,  rarely  shreddy, 
desquamation,  and,  after  the  subsidence  of  the  fever,  they  remain  in 
small  numbers  as  dirty -brown,  livid,  or  yellowish-green  spots. 

The  skin  during  the  height  of  the  febrile  stage  is  hot  and  dry.  As  the 
fever  begins  to  fall,  however,  it  becomes  moist,  and  in  many  cases, 
especially  ^vhcn  the  fever  has  fallen  by  crisis  or  rapid  lysis,  there  is 
profuse  sweating.  ^ 

With  the  subsidence  of  the  febrile  symptoms  the  tongue  regains  its 
moisture,  the  coated  patches  clear  up,  and  the  excoriations  and  fissures 
heal.  The  voice  giuns  in  strength  and  resonance,  and  the  hoarseness, 
when  due  simply  to  catarrh  or  erosions  in  the  larynx,  disappears ;  not 
infrequently,  however,  the  laryngeal  manifestations  are  quite  severe  and 
persist  for  some  time  or  may  even  be  incurable. 

The  disturbances  in  the  digestive  apparatus,  particularly  the  diarrhea, 
which  is  quite  frequently  present  during  the  second  week,  disappear 
with  the  subsidence  of  the  fever.  jMost  patients  very  soon  show  a 
good  appetite,  which,  as  will  presently  be  seen,  it  is  quite  safe  to  gratify 
with  a  comparatively  liberal  diet. 

If,  as  usually  happens  in  uncomplicated  cases,  even  before  the  fever 
has  entirely  disappeared,  the  evenmg  rise  of  temperature  becomes  less 
marked  and  the  patient  gets  a  little  uninterrupted  sleep,  he  may  in  a 
surprisingly  brief  tune  recover  from  a  disease  that  shortly  before  had 
been  the  cause  of  the  greatest  anxiety,  not  to  say  the  despair,  on  the  part 
of  his  attendants. 

Barring  complications  and  sequels,  the  duration  of  which  cannot  be 
foreseen,  the  end  of  defer^^escence  is  reached  in  the  great  majority  of  cases 
\\dthin  from  twelve  to  seventeen  days,  and  the  patient  enters  upon  the 
period  of  convalescence.  In  not  a  few  moderately  severe,  mild,  and 
abortive  forms  of  the  disease  the  febrile  period  is  ended  much  earlier. 
Cases  that  at  the  onset  were  quite  severe  may  reach  the  stage  of  defer- 
vescence in  from  six  to  ten  days ;  while  the  milder  and  abortive  cases 
may  terminate  favorably  as  early  as  the  third  or  the  fifth  day. 

When  death  is  caused  simply  by  the  severity  of  the  disease — that  is 
to  say,  by  the  toxic  effect  on  the  vital  organs — it  occurs  usually  in  the 
middle  or  second  half  of  the  second  week.  A  fatal  termination  before 
the  ninth  day,  or  as  early  as  the  fifth  or  sixth  day,  occurs  only  in  the 


MORBID  ANATOMY.  507 

most  severe  forms  of  the  disease  or  in  individuals  witli  little  resisting 
power.  Very  few  uncomplicated,  fatal  cases  last  lonj^er  than  the  second 
week. 

As  in  all  infectious  diseases,  complications  and  secjucls  may  ])r()long 
the  morbid  process  indefinitely,  and  eventually  lead  to  a  lethal  termina- 
tion. 

MORBID    ANATOMY, 

THE    EXTERNAL   FINDINGS. 

With  the  exception  of  the  not  very  numerous  cases  in  which  the 
skin  of  the  cadaver  shows  pronounced  traces  of  the  characteristic  erup- 
tion, little  that  is  peculiar  is  found  at  the  autopsy.  The  chief  findings 
are  such  as  are  always  observed  in  acute  infectious  diseases,  and  a  diag- 
nosis at  the  autopsy-table  can  at  best  only  be  made  by  exclusion. 

Owing  to  the  brief  duration  of  the  disease,  typhus  fever  cadavers 
exhibit  very  little  emaciation.  Rigor  mortis  is  often  slight,  and  lasts 
but  a  short  time.  Livid  spots  appear  early  and  in  great  profusion, 
and,  as  in  many  other  infectious  diseases  (septic  processes,  typhoid 
fever),  decomposition  begins  early,  even  in  cool  weather. 

If  death  occurred  while  the  eruption  was  present,  greenish-yellow 
or  livid,  dimly  outlined  patches,  interspersed  with  petechise  and  larger 
hemorrhagic  areas,  may  still  be  seen.  Branny  desquamation  of  the 
epidermis  may  also  be  observed,  particularly  when,  as  frequently  hap- 
pens, sudamina  were  present. 

Bed-sores  are  usually  absent,  being  found  only  when  the  patient  has 
died  of  complications  and  sequels  lasting  some  time.  In  a  few  cases 
phlegmonous  processes  or  circumscribed  areas  of  cutaneous  gangrene  are 
present  on  the  fingers,  toes,  ears,  and  tip  of  the  nose. 

The  muscles,  which,  like  the  fat,  are  not  diminished  in  volume, 
appear  red  and  dry,  and  on  section  often  have  a  dull  sheen.  Certain 
muscles'  especially  the  recti  and  the  muscles  of  the  thigh,  occasionally 
present  ulcerations  that,  from  the  presence  of  fresh  hemorrhages,  are 
seen  to  have  been  produced  during  life.  Under  the  microscope  the 
muscles  present  the  changes  described  by  Zenker  in  typhoid  fever : 
simple  atrophy  of  the  fasciculi,  with  granular  and  fatty  degeneration ; 
more  rarely,  waxy  degeneration  occurs,  which,  when  present,  is  less 
extensive  than  in  typhoid,  thus  possibly  affording  an  explanation  why 
the  peculiar  linear  or  macular  changes  producing  the  "  fish-flesh " 
appearance  so  frequently  found  in  typhoid  fever  cadavers  are  alrnost 
constantly  absent  in  typhus  fever. 

The  bones  and  joints  do  not  appear  to  have  been  carefully  investi- 


5US  TYPHUS  FEVER. 

g-ated   in  typlui-s  fever,  and  I  niyseli'  liiive  no  personal  observations  to 
offer  on   this   point. 

THE    CHANGES    IN    THE    RESPIRATORY    ORGANS. 

The  respiratory  organs  frequently,  if  not  regularly,  })resent  changes 
of  various  kinds. 

The  changes  in  the  upper  air-passages,  which  arc  so  frequent  and 
which  in  many  c])idcniics  extend  to  the  dcejier  portions,  have  already 
been  referred  to  in   describing  the  general  clinical  picture. 

Swelling,  maceration,  and  congestion  of  the  nuicous  membrane  of 
the  nose,  })harynx,  and  larynx  are  among  the  typical  findings.  In 
addition  to  these,  we  often  find  superficial  erosions  of  the  mucous  mem- 
brane and  moderate  inflammatory  enlargement  of  the  tonsils.  On  the 
other  hand,  diphtheric  changes  in  the  pharyngeal  structures,  with  the 
production  of  deep  ulcers,  are  distinctly  more  rare.  In  a  few  cases  I 
have  seen  an  extensive  diphtheric  membrane  in  the  larynx,  extending  as 
far  as  the  trachea  and  the  larger  bronchi. 

In  reports  of  many  epidemics  we  find  mention  of  extensive  sup- 
puration of  the  pharynx  and  of  severe  laryngeal  affections,  conditions 
practically  absent  in  other  epidemics  (Griessinger,  Murchison).  My 
personal  observations  were  of  a  very  unfavorable  character.  In  almost 
4  per  cent,  of  the  cases  coming  to  autopsy  I  found  intense  laryngeal 
disease,  consisting  in  marked  reddening  and  swelling  of  the  mucous 
membrane,  with  edema  and  erosions  or  fissures,  the  last  particularly 
on  the  posterior  wall,  on  the  epiglottis,  and  on  the  ventricular  bands. 
Associated  with  these  changes  I  observed  repeatedly  the  presence  of 
perichondritis,  which  in  every  instance  was  confined  exclusively  to  the 
aiTtenoid  cartilage.  The  condition  appears  to  be  generally  unilateral, 
and  it  almost  always  leads  to  necrosis  of  the  affected  cartilage,  which, 
being  in  immediate  contact  with  the  deeper  layers,  is  constantly  bathed 
by  the  pus  contained  in  the  pocket  formed  by  the  mucous  membrane. 
Weichselbaum  reports  similar  findings  in  connection  with  the  purulent 
changes  of  the  pharynx  and  larynx.  Comparing  these  changes  with 
those  observed  in  the  same  parts  in  typhoid  fever,  one  is  struck  by  an 
extraordinary  resemblance,  pointing  to  similar  causes  in  the  two  proc- 
esses, which  unquestionably  are  not  specific.  In  the  deeper  air-passages 
the  most  constant  findings  consist  in  a  catarrhal  condition  of  the  trachea 
and  bronchi,  involving  usually  their  finest  ramifications,  a  condition  that 
should  be  regarded  as  part  of  the  disease  itself  rather  than  as  a  compli- 
cation. The  mucous  membrane  is  intensely  red,  and  covered  with  a 
moderate  amount  of  tenacious  secretion  ;  occasionally  it  is  the  seat  of 


MORBID  ANATOMY.  509 

hemorrhages,  rarely  large  in  extent,  occurring  particularly  in  cases  where 
similar  changes  are  found  in  other  mucous  and  serous  mcml)rancs.  In 
4  cadavers  in  which  the  laryngeal  mucous  membrane  presented  a  diph- 
theric exudate  the  same  condition  was  found  throughout  the  entire 
bronchial  tree,  including  its  finest  ramifications. 

This  diffuse  bronchitis  is  closely  related  to  the  atelectasis  and  lobu- 
lar pneumonia  which  are  quite  frequently  found.  Hypostatic  conges- 
tion of  the  lower  lobes  was  found  in  almost  all  the  bodies  examined. 
Occasionally  there  were  found  infarcts. 

The  frequency  of  lobar  pneumonia  varies  in  the  different  epidemics 
and  in  different  localities.  While  Murchison  and  the  older  English 
writers  regard  it  as  a  rare  occurrence,  and  some  of  the  prominent 
younger  French  physicians  (Thoinot,  Netter)  do  not  even  describe  it, 
we  in  Berlin  found  lobar  pneumonia  of  one  or  several  lobes  as  the 
immediate  cause  of  death  in  15  per  cent,  of  all  our  typhus  fever 
cadavers.  The  infiltration  was  exceedingly  dense,  and  the  color  on 
section  was  a  grayish  yellow  or  an  unusually  bright  yellow,  closely 
resembling  the  appearance  generally  seen  in  fibrinous  pneumonia.  It 
remains  for  later  bacteriologic  investigations  to  show  whether  the  simi- 
larity in  the  appearances  depends  on  a  similarity  of  cause,  in  which 
case  lobar  pneumonia  must  be  considered  as  a  true  complication. 

We  may  mention  in  passing  that  pneumonias  evidently  similar  in 
character  have  been  in  more  recent  times  also  observed  in  other  localities 
(Krukenberg  and  Braunschweig,  Hampelen  and  Riga). 

A  few  authors  note  the  transition  of  pneumonia  into  gangrene  of  the 
lungs,  but  I  have  never  seen  such  a  result  follow  the  form  of  pneumonia 
just  described.  Murchison,  Griessinger,  and  others  do  not  appear  to 
have  seen  many  cases  of  gangrene.  It  is  true  that  I  have  seen  5  cases 
of  gangrene,  but  they  were  all  due  to  perichondritis  of  the  larynx, 
which  was  exceedingly  prevalent  in  the  epidemic  of  1879,  and  was 
present  in  every  one  of  the  cases  mentioned.  In  each  instance  the 
necrotic  cartilage  was  immersed  in  a  pocket  of  fetid  pus  that  had  per- 
forated into  the  interior  of  the  larynx,  so  that  aspiration  of  the  putrid 
materials  must  have  been  inevitable. 

Except  for  the  fibrinous  pleurisy  regularly  present  in  pneumonia,  few 
changes  were  observed  in  the  pleura ;  the  most  frequent  were  ecchy- 
moses  and  small  circumscribed  patches  of  fibrinous  exudate.  Serous 
exudates  are  very  rare,  while  empyema  and  fetid  effusions  in  connection 
with  putrid  changes  in  the  lungs  are  somewhat  more  frequent. 


510  TYPHUS  FEVER. 

THE    CIRCULATORY    ORGANS. 

There  is  almost  always  unilateral  dilatation  of  the  heart.  In  cases 
where  death  occurs  relatiN'cly  early,  the  muscle  is  flabby,  friable,  dull, 
and  of  a  yellowish  red  color,  with  occasionally  reddish  streaks  and 
Uncar  and  punctiUc  markings.  We  unquestionably  liavc  to  deal  with 
the  tbrm  t)t'  infectious  myocarditis  that  has  recently  been  studied  by 
the  aid  of  modern  microscopic  technic  in  typhoid  fever,  scarlet  lever, 
diphtheria,  etc.* 

In  some  of  the  older  reports  of  autopsies  the  endocardium  is  often 
described  as  dark  red  or  livid  in  color.  There  is  no  doubt  that  such 
changes  are  due  to  post-mortem  imbibition.  True  inflammatory  processes 
in  the  endocardium,  especially  in  the  valves,  are  by  common  consent 
regarded  as  among  the  greatest  curiosities  in  typhus  fever.  Pericarditis 
appears  to  be  equally  rare,     I  have  never  seen  it. 

The  condition  of  the  vascular  system  in  typhus  fever  has  not  been 
the  subject  of  much  investigation.  In  the  aorta  and  large  arterial 
trunks  I  have  found  isolated,  apparently  recent,  peculiar  yellowish 
patches.  It  is  uncertain  whether  the  circumscribed  cutaneous  gangrene 
described  in  a  former  paragraph  is  due  to  vascular  changes  ;  and  if  it  is, 
the  character  of  these  changes  is  unknown. 

The  blood  in  a  typhus  fever  cadaver  is  darker  and  more  fluid  than 
normal.  Coagulation  is  distmctly  less  marked,  and  in  the  majority  of 
cases  is  not  observed  in  the  cavities  of  the  heart. 

These  findings  tally  with  the  statements  of  older  authors  in  regard 
to  the  character  of  the  blood  taken  from  the  patient  during  life.  These 
authors  emphasize  the  diminished  coagulability  and  the  softness  and 
solubility  of  the  blood-clot,  from  which,  however,  they  draw  conclusions 
that  we  are  not  disposed  to  admit  at  the  present  time. 

THE    DIGESTIVE    ORGANS. 

In  addition  to  the  above-mentioned  changes  in  the  pharynx,  we  may 
include  among  the  alterations  at  the  entrance  of  the  digestive  tract 
occasional  excoriations  and  fissures  in  the  tongue,  with  maceration, 
hemorrhages,  and  even  ulceration  of  the  gimas.  Older  authors  speak 
of  the  noma-like  degeneration  of  the  mucous  membrane  of  the  mouth 
and  cheeks.  Nothing  of  this  kind  was  noted  in  the  more  recent 
epidemics. 

The  esophagus  is  almost  always  intact,  and  the  stomach  exhibits 
no  characteristic  alterations.  Occasionally  small  hemorrhages  are  found 
in  the  mucous  membrane,  and  in  rare  cases  lacerations  (Virchow)  that 
during  life  had  caused  an  admixture  of  blood  with  the  stomach-con- 


MORBID  ANATOMY.  511 

tents.  In  addition  to  catarrliul  phenomena,  the  intestinal  mucous 
membrane  not  rarely  presents  ecchymoses ;  in  other  respects  the  intes- 
tinal canal  is  almost  always  normal.  Infiltration  or  degeneration  of 
Peyer's  patches  and  the  solitary  follicles  is  never  found,  and  the  mes- 
enteric glands  are  accordingly  unchanged.  Very  occasionally  I  liave 
observed  slight  prominence  and  softening  of  the  follicles  in  the  lower 
portion  of  the  small  intestine.  The  statements  in  the  older  literature  in 
regard  to  the  occurrence  of  intestinal  ulcers,  especially  in  the  small 
intestine,  betray  an  error  in  diagnosis.  The  cases  were  undoubtedly 
"  ileotyphus "  (typhoid  fever),  which,  as  we  know  in  practice,  was  not 
properly  distinguished  from  typhus  fever  until  long  after  the  diiference 
between  the  two  diseases  had  been  firmly  established  on  theoretic 
grounds. 

When  ecchymoses  are  present  in  the  gastric  and  intestinal  mucous 
membrane,  they  are  usually  also  found  on  the  peritoneum,  Avhich  in  all 
other  respects  is  unchanged. 

The  liver  does  not,  as  a  rule,  present  any  variations  other  than  those 
observed  in  acute  infectious  diseases  generally,  namely,  marked  enlarge- 
ment, increased  consistency,  hyperemia,  or  distinct  signs  of  cloudy 
swelling.  A  fatty  liver,  which  is  said  to  occur  frequently  (Kruken- 
berg),  is  not,  in  my  experience,  a  common  occurrence. 

THE   SPLEEN. 

The  splenic  changes  are  not  so  constant  as  they  are  in  typhoid  fever. 

When  death  occurs  later  in  the  disease  than  usual,  the  enlargement  of 

the  spleen  is  not  infrequently  absent ;  while,  on  the  other  hand,  when 

death  occurs  between  the  eighth  and  the  twelfth  day  or  earlier,  it  is 

practically  always  present.      The  section  in  such  cases  presents  a  dull 

wine-red,  or  occasionally  dark-red,  color ;  the  markings  are  completely 

blurred  and  the  pulp  is  soft,  sometimes  even  semifluid  or  almost  fluid. 

Occasionally  we  find  infarcts,  which  in  extremely  rare  cases  may  lead 

to  rupture  (Jaquot). 

Both  the  older  and  the  more  recent  authors  agree  that  the  occurrence  of 
splenic  enlargement  is  much  less  frequent  and  the  degree  of  enlargement  is 
much  less  in  typhus  than  in  typhoid  fever.  One  of  the  most  radical  state- 
ments on  this  point  is  that  of  Barallier  (epidemic  in  the  prison  of  Toulon), 
who  found  splenic  enlargement  in  only  one-third  of  a  total  of  166  cases. 
Gerhard  found  the  enlargement  present  also  in  only  one-third,  while  Mur- 
chison  reports  finding  it  in  two-thirds  of  his  autopsies.  I  myself  investi- 
gated the  spleen  in  72  autopsies  on  typhus  fever  patients  during  the  years 
1878  and  1879.  Taking  250  grams  as  the  extreme  for  a  normal  spleen 
(Heuly),  I  obtained  the  following  results  :  Not  enlarged  in  22  cases  ;  250 
to  300  grams  in  15  ;  300  to  400  grams  in  16  ;  400  to  500  grams  in  10  ; 
500  to  600  grams  in  2  ;  600  to  700  grams  in  3  ;  above  700  grams  in  1  case. 


512 


TYPHUS  FEVER. 


This  shows  that  when  enlargement  was  j^reseut  at  all,  a  moderate  degree 
was  tlie  rule.  The  relation  of  the  splenic  enlargement  to  the  duration  of 
the  disease  in  fatal  cases  has  been  referred  to  previously.  It  is  illustrated  in 
the  following  table  of  Go  of  the  foregoing  cases,  coni|)ilc'(l  bv  my  assistant, 
Salomon  : 


Weight 

DF  THE  Spleen. 

DlRATION  OF  TitE  DISEASE. 

Normal. 

To  300 
grams. 

To  400 
grams. 

To  TiOO 
grams. 

To  600 
grams. 

To  700 
grams. 

To  800 
grams. 

7  days  

8  " 

9  " 

1 

1 
1 
2 

2 

12 

1 
1 

l' 

1 

4 

1 

1 

3" 
4 

r 

1 
3 

1 
1 

1 
1 

10     " 

1 

11  " 

12  " 

13  " 

14     '^ 

Over  14     " 

THE   GENlTaURINARY   ORGANS. 

Tlie  kidneys,   as   a  rule,   are   moderately  enlarged,  hyperemic,  and 

quite   often    in   the   condition   of  pronounced   cloudy   swelling.     Acute 

nephritis,  such  as  occurs  in  scarlet  fever,  is  mentioned  by  most  observers 

as  a  comparatively  frequent  complication. 

In  Moabit,  in  1878  and  1879,  we  found,  among  80  cadavers,  5  cases  of 
pronounced  recent  parenchymatous  nephritis.  Three  of  these  cases  were 
described  as  hemorrhagic  nephritis,  as  they  presented  hemorrhages  in  the 
kidney  substance,  in  the  mucous  membrane  of  the  pelvis,  and  in  the  upper 
portion  of  the  ureters. 

Nothing  else  peculiar  to  typhus  fever  was  seen  in  the  remaining 
portions  of  the  genito-urinary  tract  and  in  the  genitalia.  Occasional 
changes  in  the  endometrium,  suggesting  premature  labor  or  abortion, 
seem  to  show  that  typhus  fever,  like  most  other  infectious  diseases,  is 
very  likely  to  interrupt  pregnancy. 

THE   NERVOUS   SYSTEM. 

The  nervous  system  in  typhus  fever  has  received  little  attention, 
notwithstanding  the  prominent  part  it  plays  in  the  symptomatology. 
Hyperemia  of  the  surface  of  the  brain,  edematous  infiltration  and 
opacity  of  the  pia  mater,  and  an  increase  in  the  ventricular  fluid,  which, 
as  a  rule  clear,  may  occasionally  become  hemorrhagic,  arc  the  mo.st 
important  changes  noticed  with  any  regularity.  True  meningitis  appears 
to  be  very  rare,  or  at  least  to  occur  only  in  certain  epidemics.  Per- 
sonally, I  have  not  met  with  a  case  of  it  at  the  autopsy-table.  Ham- 
pelen,  on  the  other  hand,  mentions  4  cases  of  purulent  meningitis  in  the 
epidemic  studied  by  him. 

Meningeal  hemorrhages  are  distinctly  more   frequent.      Every  one 


SYMPTOMATOLOGY.  513 

acquainted  with  tlie  morbid  anatomy  will  recall  a  few  cases  of  circum- 
scribed meningeal  hemorrhages^  scjmetimes  so  extensive  as  t(j  cover  an 
entire  hemisphere. 

On  the  other  hand,  hemorrhages  into  the  brain-substance  are  dis- 
tinctly rare.  The  tissues  of  the  brain  are  usually  softer  than  normal 
and  exude  a  serous  fluid.  The  thickening  and  whitish  opacity  of  the 
pia  mater  and  of  the  dura,  which  is  closely  adherent  to  the  cranium, 
and  the  increase  in  the  Pacchionian  bodies,  are  merely  signs  of  chronic 
alcoholism,  so  frequent  in  typhus  fever  patients. 

As  to  the  spinal  cord,  a  few  authors  have  mentioned  increase  in  the 
quantity  of  the  spinal  fluid.  In  regard  to  changes  in  the  peripheral 
nervous  system,  nothing  is  known. 

SYMPTOMATOLOGY. 

Whereas  the  anatomic  changes  in  typhus  fever  are  quite  indefinite 
and  present  so  little  that  is  characteristic  that  it  is  exceedingly  difficult 
to  make  a  diagnosis  at  the  autopsy-table  without  an  accurate  knowledge 
of  the  patient's  condition  during  life,  the  clinical  course  of  the  disease,  at 
least  in  well-developed,  severe  or  moderately  severe  cases,  is  so  charac- 
teristic that  it  may  be  said  to  follow  certain  definite  laws.  Such  un- 
varying regularity  is  found  in  but  few  other  diseases,  except  possibly  in 
the  acute  exanthemata.  Although  the  cause  of  typhus  fever,  Kke  that  of 
the  acute  exanthemata,  is  still  unknown  to  us,  we  may,  nevertheless, 
assume  the  existence  of  a  micro-organism,  the  effects  of  whose  develop- 
ment and  activity  on  the  body  of  the  individual  attacked  are  so  marked 
as  far  to  outweigh  in  importance  any  of  his  constitutional  or  acquired 
peculiarities.  Indeed,  these  effects  are  much  more  marked  than  is  the 
case  in  many  other  infectious  diseases,  especially  in  typhoid  fever.  It  is 
to  this  micro-organism  that  we  attribute  the  regular  mode  of  onset  and 
ending  of  the  disease,  its  well-defined  duration,  the  regularity  with  which 
certain  symptoms,  especially  the  eruption,  appear  and  disappear,  and  the 
peculiar  character  of  the  temperature-curve.  The  latter  is  of  such  vital 
importance  in  the  diagnosis  and  prognosis  of  the  disease  that  we  accord 
it  the  first  place  in  the  following  discussion, 

THE   TEMPERATURE. 

This  was  first  subjected  to  careful  study  by  Wunderlich.^  His  results 
were  later  confirmed  by  Griessina:er,  Moers,  and  others.  In  the  main, 
these  original  results  obtained  by  Wunderlich  still  hold  good  at  the  present 
day. 

>  Arr./i.  f.  phi/.nol.  Heilk.,  Bd.  i.,  S.  177,  and  Das  Verhalten  der  Eigenivainne  in 
Krankheiten,  Leipsic,  1870,  2.  Aufl. 
38 


514 


TYPHUS  FEVER. 


The  Temperature  in  the  Beginning  and  I^ater  Stages. — 

The  lover  is  u?;lieivd  in  by  one,  i»r  possibly  several,  eliills,  more  rarely 
by  a  vague  sensation  of  chilliness,  and  the  temperature  rises  rapid) v,  so 
that  as  early  as  the  evening  of  the  first  day  it  may  exceed  39°,  and  not 
rarely  reaches  40°.  After  a  moderate  remission  of  not  more  than  half 
a  degree  on  the  following  morning,  the  temperature  conthuics  to  rise 
steadily,  and  on  the  evening  of  the  second  day  goes  beyond  the  point 
reached  on  the  preceding  day,  registering  40.5°  and  over.  After 
another  lapse  of  twenty-fotir  hours,  -with  a  very  slight  morning  remis- 
sion, it  reaches  41°  and  even  higher.  In  most  cases  another  rise  is 
noted  on  the  evening  of  the  fourth  day  (compare  Fig.  48).  I'his  rapid 
rise  in  the  curve  distinguishes  typhus  from  typhoid  fever,     A  gradual 


pjiy  of  the  disease. 

T.    1     2    3     4    5     6     7    8     3    1 

0    11    12    13    14    15    15   17    18    19 

1           ' 

+  :t 

~h^    "' — H  :  ; 

'1                                             1\ 

-»         fititiiti:        J 

»~fj  ♦  A   »       A 

ii__:4  Sz/jjA     JS 

A     .         1      1                III 

^    t            J^^    1    EIu 

hi    I       -^it            ±ltl^ 

iTiLin     ,,  [/ v^ff  i      i 

\l      1        X-Z            it       J 

4-3          1/'       y    yi    •■    «     J          * 

^--  uiiti    i-^j 

I 

u  itittiit    d 

^  i   \               -^ 

i  ^     iL  It         -^  d 

?J    *                          4^ 

I  i  iti       i    4 

«    t* 

i!            1      1                            i 

-t                        1^ 

-f-    --J-I^                  tij 

2                                it 

_^    '    [1^^ ^         '    ^ 

i     i 

it          ^    ■    \t  Itlt^-^- 

^rrr       T 

38 

it    ltd 

it          ♦^^tl        4 

■    -^-^i  '  t 

Zlirq^      H 

1 

x±:     -1 

^aitit 

1    I 

it          ±2112512^ 

lllltit                 VZa^^ 

'      '      •           1               "    V 

1  1      1  ' 

;   '     1 

It    1 

1      1   j 

35  -L-    -J-       j            1    ~|            ! 

^-^iii   ±11 1^3 

Fig.  48.— Severe  case  of  typhus.    Typical  fever-curve  (in  part  diapri.mmaiic). 

rise  in  the  temperature  to  its  highest  point,  such  as  occurs  in  the  latter 
disea.se,  would  be  a  great  exception,  and  cases  of  typhus  are  quite  fre- 
quent in  which  the  highest  point  is  reached  at  the  end  of  thirty-six, 
twenty-four,  or  even  in  a  ver}^  few  hours  (compare  Fig.  57).  During  the 
second  half  of  the  first  week  the  curve  persists  at  the  same  height,  with 
moderate  morning  remissions  not  exceeding  0.5°,  or  it  continues  to  rise 
slowly  until  the  eighth  day,  so  that  in  severe  cases  the  thermometer  at 
this  period  may  register  41  °  or  over.  The  behavior  of  the  curve  during 
the  first  week  of  the  disease  is  so  v^ery  peculiar  as  to  be  of  the  highest 
diagnostic  value.  While,  on  the  one  hand,  it  rules  out  typhoid  fever, 
the  diagnosis  of  any  other  of  the  exanthemata  is  equally  improbable,  as 
in  none  of  these  diseases,  much  as  they  resemble  typhus  fcA'cr  in  other 


SYMPTOMA  TOLOa  Y. 


515 


respects,  do  we  have  the  same  rise  and  uniformity  of  the  temperature 
during  the  first  week  of  the  disease  (Fig.  48). 

Most  of  the  modern  authors,  evidently  on  Wunderlich's  authority, 
mention  the  occasional  occurrence  of  a  characteristic  drop  in  the  tem- 
perature at  the  end  of  the  first  week,  usually  on  the  evening  of  the 
seventh  day.  They  are  inclined  even  to  accord  it  some  diagnostic 
value.  There  can  be  no  question  as  to  the  fact,  since  it  has  been 
reported  by  a  goodly  number  of  reliable  observers,  but  it  is  probable 
that  the  phenomenon  does  not  appear  with  the  same  frequency  in  every 
epidemic.  Of  the  440  cases  in  my  hospital  analyzed  by  Salomon,  this, 
temporary  fall  in  the  temperature  was  noticed  in  only  3  cases  (Fig.  49). 


Day  of  the  disease.                                                            Day  of  the  disease. 

T.    3     4    5     6     7     8    3    10 

1    12    13    14    15    16    17            T.    7     8     3    10    11    12    13    14    15    16    17    18    19   20 

41 

*■          I 

f>                                                                                  -          t           t 

t       '^       K 

*■-                                                               *     »     S           t           I 

-51                                        An                      B    5     -     *     t 

^  .,5,_2_d_  ,   ^     S^5_ 

_:i 40 \._2^.J.   . 

2  H        «        1   h  5 

— 5 U"i  Z        •   I 

S            ~    t   I       u 

1       »H  "T  rf  r^_ 

t           t 

3     £53        »    Y_ 

■\<>t 

,n  J  ri  -tsr        -  -  ■ 

-♦             -                    38  i    ri          *-                   _     _     .         ^» 

'                                                »                                                    t 

I                                                                                                   I 

t 

00                                              ' 

OH 

:                                                      t 

37 

_:      _      _      37^        l_ 

I                     ±1    1 V 

±     5       -,                                                          _^  r^ 

^       ^  ^                                                        5^ 

^     -1  b'^        oc                                            I  i 

36 

j,2_^              3G                                                               ♦»- 

2 

35 

1                       85 

=       ±        '                              "     ~                            ~ 

Fig.  49. — Peddler,  eighteen  years  old.  Moder- 
ately severe  case  of  typhus  fever.  Remission  on 
the  evening  of  the  seventh  day  of  the  disease. 


Fig.  50.— Apprentice,  seventeen  years  old. 
Moderately  severe  course.  Marked  precritical 
variations  in  the  curve. 


A  few  clinicians  (Lebert)  attach  some  value  to  the  observation  that 
even  in  severe  cases  the  temperature-curve  presents  marked  irregulari- 
ties as  early  as  the  last  days  of  the  first  week,  affecting  particularly  the 
daily  variations.  This  is,  I  believe,  true  of  the  milder  cases  ;  but  when 
the  disease  runs  its  full  course  and  the  case  is  a  grave  one,  the  phenom- 
enon, in  my  experience,  does  not  occur.  On  the  contrary,  the  fever, 
which  is  of  a  continued  remittent  type  in  such  cases,  usually  persists  at 
the  same  height  until  the  first  days  of  the  second  week,  or  there  is  a 
perceptible  remission  during  the  morning  hours,  while  the  evening 
temperature  remains  constantly  high. 

After  the  tenth  and  eleventh  days  of  the  disease,  sometimes  as  early 


516  TYPHUS  FEVER. 

as  the  ninth,  a  marked  evening  reniistjiou  begins  to  aj)pcai'  (compare 
Figs.  48  and  61),  and  the  curve  becomes  distinctly  more  irregular,  often 
showing  marked  intermissions.  In  the  severest  cases,  where  the  prog- 
nosis is  very  bad,  the  fever  continues  high  even  during  the  last  days  of 
the  (second)  week,  and  occasionally  rises  to  great  heights.  In  such 
cases  the  ominous  phenomenon  of  color  mordax  is  particularly  marked. 

The  beginning  of  defervescence  in  severe  and  moderately  severe  cases 
ending  ui  recovery  is  noted  at  the  end  of  the  second,  or,  rarely,  during 
the  first  days  of  the  tiiird,  week.  I  observed  it  most  frequently  between 
the  twelfth  and  the  fifteenth,  and  exceptionally  on  the  sixteenth  or 
the  seventeenth,  day  of  the  disease.  The  permanent  subsidence  of  the 
temperature  that  folloAVs  in  the  great  majority  of  cases  is  (occasionally 
preceded  by  a  period  of  from  twenty-four  to  thirty-six  hours  (compare 
Fig.  50),  during  which  there  are  marked  variations  in  the  curve,  with 
severe  and  very  alarming  disturbances  in  the  patient's  general  condition. 
Kot  infrequently  there  is  an  extreme  rise  of  temperature,  to  the  height 
of  41°  or  even  42°,  followed  within  from  twelve  to  eighteen  hours  by 
a  fall  below  the  temperature  of  the  preceding  morning  (compare  Figs.  48 
and  61),  whereupon  the  final  fall  by  crisis  or  lysis  usually  occurs  without 
any  further  mterruption.  The  older  authors  have  described  this  by  the 
expressive  term  perturbatio  critica  (Fig.  51). 

A  contrary  (precritical  fall)  beha^'ior  of  the  cur\e  is  a  distinctly  rarer 
occurrence.  Immediately  preceding  the  permanent  subsidence  of  the 
fever,  the  temperature  suddenly  falls  to  the  normal  or  below  it,  and 
within  twelve  hours  or  less  returns  to  or  a  little  beyond  its  former 
height.  This  so-called  "  pseudocrisis  "  is  immediately  followed  by  the 
final  fall  in  the  cui've  (Fig.  52). 

The  Period  of  Defervescence. — The  temperature-course  during 
the  stage  of  defervescence  strikingly  recalls  what  occurs  durmg  the 
initial  stage.  The  abruptness  and  rapidity  with  w^hich  the  fever  rises 
are  usually  pnralleled  by  the  completeness  with  which  the  temperature 
falls  to  or  below  the  normal  within  a  few  hours  or  days.  It  is  not  at 
all  a  rare  occurrence  for  the  temperature  to  fall  at  one  drop,  usually 
during  tl^e  ni<rht,  from  a  considerable  height — 40°  and  above — to  37° 
or  even  less  (Fig.  53).  More  frequently  this  fall  is  interrupted  by  a 
temporary  rise  in  the  curve,  the  temperature  at  first  sinking  to  38.5° 
or  38°,  and  then,  toward  evening,  mounting  1°  or  1.5°  before  its 
final  return  to  the  normal,  where  it  then  persists  practically  without 
interruption. 

With  almost  equal  frequency,  instead  of  this  single  interruption, 
the  fall  of  the  temperature  may  present  a  step-like   curve   extending 


SYMPTOMATOLOG  Y. 


517 


over  from  three  to  four  days  (compare  Fig.  01),  while  an  even  more 
gradual  ending  of  the  curve  by  distinct  lysis  is  rnucii  rarer  (Fig.  54) 

Diiy  of  the  (li^oasr. 


Fig.  51.— Woman,  thirty-three  years  old.    Very  severe,  uncomplicated  case  with  great  cardiac 
weakness.    Marked  precritical  rise  in  the  temperature. 

The  tendency  to  marked  intermission  during  the  period  of  defer- 
vescence, which  is  almost  typical  of  typhoid  fever,   is  very  slight  in 

Day  of  the  disease.  Day  of  the  disease. 


T     6     7     8     9     ID    II     12    13    14 


I?;: 


m 


% 


?.l 


Fig.  52. — Man,  thirty-one  years  old.    Severe  case  Fig.  53. — Man.  nineteen  years  old.    Mod- 

of  typhus  fever.    Pseudoerisis  on  the  twelfth  day       erately  severe  case  of  short  duration.    Dis- 
of  the  disease.  tinct   fall   by  crisis,   preceded   by  a  pro- 

nounced precritical  rise. 

typhus  fever.     As  we  have  seen,  we  find  only  occasional  cases  (compare 
Fig.  50)  in  which  the  final  subsidence  of  the  fever  is  preceded  by  a 


518 


TYPHUS  FEVER. 


jH'i-iod   lasting  two  or  three  days,  during  which  there  are  considerable 
variations  in  the  curve,  with  loM'  morning  and  very  high  evening  tem- 


liav  of  thr  liisiiist 


Fig.  54.— Foreman,  iwunty-eight  years  old.    Onset  severe;   subsequent  course  mild  and  short, 
with  a  very  protracted  period  of  defervescence. 

peratures.     This  phenomenon  has  received  special  attention  from  Rosen- 
stein,  who  appears  to  have  observed  it  frequently. 


Day  of  the  disease. 

p 

T     ?     3     4    5     6     ;     8     9     10 

11     1?    13    14    15    16    n    18 

180 

T    -"■ 

41 

160 

A            .     * 

_,  '^  -^  f\  A       ' 

4o",--A-:-^5^-^--p4- 

J40 

120 

17  ,r~       z~  ~~ 

i  ^  i           A 

"           I 

«  4                             ' 

39  i                       _                   .1 

-   --                  A 

.    . ..     ..           T_ 

1 

•^ft  -  -      ^          -.^ 

yl 

^^        .     v^A   A  7 

1    1 

100 

.,^-^4            u\^    C 

'-^  \Z             V     ^i.  n 

I  t          t 

^A 

\\    I 

,,                                1 

l\^  L               --■    -  ■ 

^i\,Ji  jL       .... 

80 

»     t\'^     A 

.  .-X-^-M     .^-        .^   . 

\        -  \\r.  ^  ,^ .. 

..         -\rs  J    1  \C'^  - 

60 

it           V              \  ■  f  ; 

>^ ..  . 

i 

_i    _.  .  .    .. 

Fig.  55.— Woman,  twenty-seven  years  old.    Severe  course  during  the  lirst  week  ;  very  short  dura- 
tion.   Besfinning  of  defervescence  on  the  ninth  day  of  the  disease. 

Temperature  Variations  in  Different  Forms  of  the  Dis- 
ease.— In  severe  and  moderately  severe  cases  the  febrile  period,  as 
has  previously  been  stated,  usually  ends  between  the  fifteenth  and  the 


SYMPTOM  A  TO  LOG  Y. 


519 


twentieth  day.  Sometimes,  tliougli  rarely,  uncomplicated  cases  remain 
febrile  until  the  beginning  or  even  tlie  end  of  tlu;  fourth  week. 

Cases  that  bcghi  to  recover  before  the  end  of  the  second  week 
belong  to  the  milder  forms  of  the  disease.  Tlie  lessening  of  the  dura- 
tion affects  chiefly  the  fastigium,  during  which  the  temperature  may  be 
quite  high.  Cases  are  not  at  all  rare  in  which  there  is  an  evening  tem- 
perature of  40°  or  even  41°  C,  persisting  until  the  end  of  the  first  week, 
with  a  morning  temperature  of  not  much  lower  than  40°  (Fig.  55), 
Others,  again,  present  marked  remissions  and  intermissions  of  the  curve 
during  the  very  first  days,  but  even  in  such  cases  the  evening  temper- 
ature rises  to  a  higher  point  than  is  commonly  observed  during  the  first 
week  of  typhoid  fever. 

The  initial  stage  also  is  frequently  abridged  in  the  milder  cases — 

Day  of  the  disease. 


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Fig.  56.— Waiter,  eighteen  years  old. 
Mild  case  with  relatively  low  tempera- 
ture.   Precritical  rise. 


Fig.  57.— Man,  twenty-three  years  old.  Mild  case  of 
typhus  fever  following  immediately  upon  an  attack 
of  recurrent  fever.  Abrupt  rise  of  the  temperature 
without  remission,  and  gradual,  step-like  deferves- 
cence. 


more  frequently,  perhaps,  than  in  the  severe  ones.  The  fever  may 
attain  its  height  in  from  twenty-four  to  thirty-six  hom'S,  either  at  one 
bound  or  with  a  single  interruption.  Among  the  cases  that  have  come 
under  my  observation  during  the  first  days  I  have  never  observed  a 
gradual  rise  of  the  fever  followed  by  an  abortive  course.  On  the  other 
hand,  the  period  of  defervescence  is  more  often  protracted  in  mild  cases 
than  it  is  in  severe  ones,  in  which  the  course  of  the  disease  is  not 
abridged.  In  such  mild  cases  I  have  often  observed  a  gradual,  step-like 
fall  of  the  temperature,  covering  from  five   to  eight  days,  down  to  or 


520 


TYPHUS  FEVER. 


even  below  the  normal  (Fig.  57).  The  daily  variations  arc  nsually 
comparatively  slight.  A  tcrniinatii)n  of  the  fever  bv  crisis,  lasting  not 
more  than  from  twelve  to  eighteen  hours,  appears,  on  the  t)tlK'r  IkukI,  to 
be  no  more  frequent  in  mild  than  in  severe  ciises. 

Very  mild  or  distinct  abortive  forms  of  typhoid  fever  have  not  as 
yet  received  very"  careful  study.  My  own  observations,  especially  in 
regard  to  the  course  of  the  temperature,  are  incomplete.  The  accom- 
panying illustration  (Fig.  58) — the  history  of  the  case  will  be  given 
later — shows  that  the  temperature  may  reach  a  considerable  height  after 
a  rapid  initial  rise.  Cases  with  very  low  temperatures,  or  practically 
afebrile,  such  as  the  typhoid  fever  expert  is  so  familiar  with,  I   have 


Day  of  the  disease. 

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Fig.  58. — Woman,  thirty-one 
years  old.  Abortive  case  of  ty- 
phus fever  with  severe  onset. 


Fig.  59.— Laborer,  forty-two  years 
old.  Excessively  high  temperature 
immediately  preceding  death. 


rarely  observed  in  typhus  fever,  but  I  would  not  care  to  affirm  that 
they  are  in  reality  rarer  than  in  typhoid  fever. 

In  those  fatal  cases  in  which  the  patient  succumbs  to  the  severity 
of  the  intoxication  and  not  to  complications,  the  temperature-curve  is 
usually  shorter  than  in  the  severe  ones  ending  in  recover}\  The 
great  majority  of  such  cases  are  characterized  by  violent  onset  and 
chill  and  an  unusually  high  temperature  from  the  veiy  beginning,  with 
slight  morning  remissions.  Death  usually  occurs  between  the  ninth  and 
the  twelfth  day — rarely  as  late  as  the  sixteenth  day.  A  perceptible 
preagonic  rise  in  the  temperature  is  a  common  phenomenon  (Fig.  59). 
In  one  of  my  cases  the  thermometer  registered  42.2°  C,  and  Wunderlich 


SYMPTOM  A  TO  LOG  Y. 


)21 


Day  fjf  tho  disonso. 


reports  a  case  in  which  the  temperature  was  43°.  I  was  frc(|iiently 
able  to  determine  a  marked  rise  in  the  rectal  temperature  after 
death. 

Of  the  causes  that  determine  a  prea^^onic  rise  of  temperature  we 
Imow  nothing,  nor  can  we  give  any  more  definite  information  in  regard 
to  those  cases  in  which  death  was  immediately  ])receded  by  a  rapid  fall 
of  temperature  far  below  the  normal.  The  accompanying  illustration 
shows  a  terminal  temperature  of  33°  C.  (Fig.  60). 

In  isolated  cases,  preferably,  as  it  would  appear,  in  individuals  re- 
duced by  want  and  illness,  this  ominous  fall  in  the  temperature  lasts 
several  days.  The  pulse  gradually  di- 
minishes in  tension  and  becomes  so  rapid 
that  it  cannot  be  counted.  The  patients 
become  cyanotic,  and  the  temperature 
steadily  falls  until  life  finally  ebbs 
away  in  almost  imperceptible  degrees. 
The  occurrence  of  marked  intermittent 
variations  in  the  curve  preceding  a  lethal 
termination,  of  which  Wunderlich  gives 
an  illustration,  did  not  come  within  my 
experience. 

Sweating  in  Typhus. — This  de- 
scription of  the  behavior  of  the  tem- 
perature may  be  properly  concluded 
by  a  few  remarks  on  the  occurrence  of 
sweats  during  typhus  fever,  a  point 
that  has  been  accorded  undue  promi- 
nence by  the  older  authors  belonging 
to  the  humoral  school  of  pathology. 

During  the  initial  stage,  and  at  the 
height  of  the  fever,  whether  the  case  be 
mild  or  severe,  the  skin  is  almost  always    ^^^^ 
hot  and  dry.     Only  in  very  rare  cases, 
where  the  initial  rise  of  temperature  is  followed  by  a  marked  remission 
lasting  several  days,  is  sweating  occasionally  observed. 

During  the  fall  by  crisis  the  skin  is  usually  more  or  less  moist ; 
rarely,  there  may  be  profuse  sweating.  The  occurrence  of  the  latter  is 
distinctly  more  common  in  lethal  cases  about  the  time  of  the  ominous 
fall  in  the  temperature. 

The  offensive  or  even  specific  odor  of  the  perspiration  mentioned  by 
older  authors  I  have  never  been  able  to  observe,  perhaps  because  the 


60.- 


Vagabond,  twenty-three  years 
old.    Alcoholic. 


522 


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SYMPTOMA  TOLOG  Y.  52.3 

ventilatiou  in  the  barracks  at  Moabit  was  carri(;(l  out  with  such  pains- 
taking care  as  is  rarely  possible  under  other  conditions. 

ALTERATIONS  IN  THE  CIRCULATORY  ORGANS. 

The  changes  in  the  circulatory  organs,  especially  the  cardiac  clianges 
in  acute  infectious  disease,  have  recently  been  studied,  especially  by  my 
students,  Krehl,  Romberg,  and  Piissler,  with  such  signal  results  that  it 
becomes  a  matter  of  the  utmost  importance  that  in  future  epidemics 
our  newest  acquirements  in  this  direction  should  be  tested  by  a  careful 
examination  of  the  behavior  of  the  heart  in  typhus  fever.  As  cardiac 
dilatation  and  certain  marked  alterations  in  the  heart-muscle  are  usually 
observed  in  the  cadaver  (see  the  section  on  Pathologic  Anatomy),  so 
also  there  occur  clinically  such  early  and  marked  effects  of  the  toxins 
on  the  heart,  and  probably  on  the  vasomotor  nerves,  as  occur  m  few 
other  infectious  diseases. 

The  Pulse. — From  a  prognostic  point  of  view,  therefore,  the  con- 
dition of  the  pulse  from  the  very  beginning  of  the  disease  is  quite  as 
important  as,  if  not  more  so  than,  that  of  the  temperature  or  even  of 
the  nervous  system. 

Even  during  the  initial  stage,  in  severe  and  moderately  severe  cases, 
and  usually  also  in  milder  cases,  the  pulse  attains  a  considerable  fre- 
quency, and  this  occurs  among  vigorous  young  men  as  well  as  among 
women  and  children  and  older  individuals  (compare  Fig.  61). 

In  women  the  pulse-rate  after  thirty-six  hours  often  reaches  110, 
with  slight  morning  remissions,  which  are  less  marked,  however,  than 
commonly  occurs  in  typhoid  fever.  In  children  the  j)ulse-rate  is  con- 
siderably higher,  and  even  in  vigorous  young  men  an  evening  pulse-rate 
of  from  110  to  120,  with  a  morning  fall  to  90  or  100,  is  observed  as 
early  as  the  third  day. 

In  severe  cases  ending  in  recovery  the  pulse-rate  persists  at  the  same 
height  during  the  first  week,  with  even  smaller  daily  remissions  than 
were  present  at  first.  Usually,  at  the  end  of  the  first  Aveek  an  additional 
rise  in  the  frequency  occurs. 

Except  in  cases  with  a  very  bad  prognosis,  the  volume  and  ten- 
sion of  the  pulse  are  usually  good  during  the  first  week.  Toward 
the  end  of  the  week  the  pulse  is  likely  to  become  soft  and  more 
compressible. 

The  occurrence  of  dicrotism,  so  common  in  typhoid  fever,  I  find  to 
be  by  no  means  frequent,  and  my  experience  in  this  respect  agrees  with 
the  observations  of  reliable  authors  (Griessinger,  Murchison,  and  others). 
It  was  present  in  5.9  per  cent,  of  all  my  cases.     In  more  than  half 


524  TYPHUS  FEVER. 

of  the  Ciises  it  appcaral  dul'iug-  the  height  of  the  disease  and  persisted 
for  some  time ;  in  the  remainder  it  lasted  only  from  two  to  three  days, 
occurring  prineij)ally  dnring  the  period  of  defervescence.  I  do  not 
remember  ever  to  have  observed  the  phenomenon  either  dnring  the 
initial  stage  or  during  the  first  days  of  the  first  week. 

During  the  second  week  in  severe  eases,  even  in  such  as  end  in 
recover}-,  the  rate  continues  high  and  the  pulse  becomes  smaller  and 
weaker,  sometimes  intermittent,  so  that  in  some  cases  for  days  it  can  be 
felt  and  counted  only  with  great  difficulty.  Absence  of  the  apex -beat 
on  palpation,  increase  of  the  area  of  cardiac  dulness  to  the  right  and 
left,  and  muffled  hairt-sounds,  j)oint  to  acute  dilatation  following  intense 
infectious  changes  in  the  myocardium.  jNIarked  cyanosis  of  the  face, 
hands,  and  feet  at  this  time  is  a  very  unfixvorable  symptom.  It  occurs 
usually  in  alcoholics,  in  sufferers  from  chronic  disease,  or  in  those  who 
have  just  recovered  from  some  acute  affection,  and  almost  all  the 
patients  iu  whom  it  is  present  die.  However,  I  have  known  individ- 
uals who  were  well  nourished  and  vigorous  to  recover  in  spite  of  this 
ver}'  grave  symptom. 

Whether  the  extreme  cardiac  wealoiess  has  any  connection  with  the 
gangrene  of  the  tip  of  the  nose,  ears,  toes,  and  fingers  which  occurs  in 
severe  cases  is  an  interesting  question  that  still  remains  to  be  solved. 
It  seems  probable,  however,  that  the  gangrene  depends  in  part  on  the 
specific  changes  in  the  vessel-wall,  with  thrombus-formation,  etc.,  con- 
ditions that  have  been  shown  to  play  a  part  in  the  process  in  typhoid 
fever. 

A  retardation  of  the  pulse-rate,  particularly  a  low  pulse-rate  in  pro- 
portion to  the  temperature,  which  is  so  characteristic  of  typhoid  fever 
in  previously  healthy  young  men,  I  have  observed  only  exceptionally  in 
typhus  fever,  and  then  only  in  mild  cases.  Its  occurrence  iu  severe 
cases  (Griessinger)  I  have  never  observed.  During  the  period  of  defer- 
vescence, the  pulse,  which  in  severe  cases  has  been  weak  and  irregular, 
gradually  gains  in  strength,  and  the  pulse-rate  begins  to  diminish  (com- 
pare Fig.  61).  If  there  has  been  marked  cardiac  weakness  with  dila- 
tation, the  pulse,  after  the  normal  or  subnormal  temperature  has  been 
reached,  continues  between  80  and  90  in  the  mornmg  and  reaches 
100  in  the  evening,  and  is  exceedingly  unsteady,  so  that  any  trivial 
bodily  or  mental  excitement  is  followed  by  a  considerable  temporary 
acceleration. 

In  other  cases,  marked  by  a  moderately  severe  or  mild  course,  the 
pulse-rate  diminishes  pari  passu  with  the  fall  in  the  temperature,  the 
physiologic  pulse-rate  being  reached  within    twenty-four  or  thirty-six 


SYMPTOMATOLOGY.  525 

hours  in  cases  ending  by  crisis,  and  in  from  three  to  five  days  in  those 
ending  by  lysis. 

A  renewed  rise  in  the  pulse-rate  during  the  period  of  convalescence 
occurs  only  in  those  severe  cases  witli  marked  cardiac  involvement, 
when  the  patient  has  left  his  bed  too  early  ;  or  it  may  occur  as  a  mani- 
festation of  some  complicating  condition,  Tlie  pulse-rate  during  tlie 
period  of  convalescence  occasionally  falls  to  below  the  normal,  as  low 
as  50  or  48,  and  may  remain  at  that  point  for  from  eight  to  four- 
teen days.  The  cause  of  this  bradycardia  has  never  been  properly 
explained.  It  also  occurs  in  other  acute  infectious  diseases — diphtheria, 
typhoid  fever,  and  scarlet  fever — and  has  no  ominous  significance.  It 
was  known  to  the  older  authors  (Barallier,  Kennedy,  Murchison,  Gries- 
singer). 

The  State  of  the  Heart  and  Blood-vessels. — In  typhus  as 
in  typhoid  fever,  the  myocarditis  in  the  great  majority  of  cases  appears 
to  undergo  complete  involution.  I  cannot  remember  a  single  case  in 
which  there  remained  any  chronic  insufficiency  of  the  heart-muscle  if 
the  integrity  of  the  organ  was  established  beyond  a  doubt  before  the 
beginning  of  the  disease. 

The  same  is  true  of  valvular  lesions,  which  neither  I  nor  anyone 
else  has  ever  observed  as  sequels  of  typhus  fever.  We  may  accord- 
ingly infer  that  acute  endocarditis  must  be  very  rare.  The  same  may 
be  said  of  pericarditis.  I  never  found  any  inflammatory  deposits  or 
exudates  at  the  autopsies,  and  only  once  or  twice  heard  a  temporary 
pericarditic  friction. 

Of  the  changes  in  the  blood-vessels,  the  arteries,  and  veins,  but 
little  is  known.  As  in  all  acute  infectious  diseases,  the  period  of  con- 
valescence from  typhus  fever  is  marked  by  the  occasional  occurrence  of 
so-called  marantic  thrombi  in  the  veins,  especially  in  the  veins  of  the 
legs.  They  are  most  frequent  in  patients  whose  vital  powers  have 
been  sapped  by  want  or  chronic  disease,  and  in  those  who  have  suffered 
from  a  severe  form  of  typhus  fever. 

Changes  in  the  Blood. — The  state  of  the  blood  in  typhus  fever 
has  been  repeatedly  referred  to  in  the  sections  on  Morbid  Anatomy  and 
Etiology. 

The  records  bequeathed  to  us  by  former  observers  in  regard  to 
the  color  and  coagulability  of  the  blood  no  longer  possess  the  signifi- 
cance attributed  to  them  by  the  older  authors.  Little  as  we  have 
learned  by  microscopic  examination  in  regard  to  the  specific  cause  of 
the  disease,  a  few  valuable  observations  have  been  obtained  in  regard 
to  the  blood-coi'puscles.     While  the  shape  and  appearance  of  the  red 


526  TYPHUS  FEVER. 

corpuscles  is  unaffected  in  the  main,  their  number  is  diminished  in 
well-marked  cases  at  the  height  of  the  disease,  and  the  anemia  persists 
durincT'  the  period  of  convalescence.  Correspondino:  to  the  oligocythemia 
Avc  find  a  reduction  in  the  hemogU)bin  during  the  latter  days  of  the  first 
and  during  the  second  \vcck.  Mey  found  this  reduction  to  be  from  10 
to  15  per  cent,  in  ti  cases  that  he  examined. 

On  the  other  hand,  the  white  blood-cells  appear  to  be  increased  in 
number  (Combemale).  This  appears  to  be  a  special  feature  of  the 
disease,  and  it  affords  a  very  important  aid  in  the  differential  diagnosis 
from  t\"phoid  fever,  which,  as  is  well  known,  is  marked  by  a  diminu- 
tion rather  than  by  an  increase  in  the  number  of  the  leukocytes. 

In  those  cases  in  which  serum  tests  have  been  made,  it  has  been 
found,  as  was  to  be  expected,  that  the  serum  has  no  agglutinating  effect 
on  the  bacillus  of  Eberth.  This  fact  is  of  the  greatest  importance  in 
differential  diagnosis. 

THE   SPLEEN    AND    LYMPH-GLANDS. 

The  discrepancies  in  the  statements  of  various  authors  in  regard 
to  the  state  of  the  spleen  in  typhus  fever  present  a  marked  contrast  to 
the  uniformity  of  the  observation  in  regard  to  the  organ  in  typhoid 
fever. 

While  a  few  authors  affirm  that  the  spleen  is  always  enlarged,  others, 
as  Oesterlen-Dorpat  and  the  English  writers,  regard  splenic  enlargement 
as  rare,  or  even  as  constantly  absent,  in  typhus  fever.  The  want  of 
agreement  on  this  point  is  so  marked  that  it  cannot  be  altogether 
explained  by  differences  in  the  character  of  the  disease  due  to  local 
conditions  or  to  different  periods  of  the  epidemic. 

According  to  my  own  experience,  enlargement  of  the  spleen  can  be 
determined  clinically  much  more  frequently  than  at  the  autopsy  table  in 
the  great  majority  of  severe  and  moderately  severe  cases  and  in  many 
milder  ones,  providing  the  examination  can  be  made  early  enough. 
This  difference  l^etween  the  clinical  and  anatomic  findings  points  to  the 
main  reason  why  authors  fail  to  agree ;  it  is  that  they  made  their  exam- 
inations at  different  stages  of  the  disease.  I  have  alwavs  observed 
enlargement  of  the  spleen  very  early,  distinctly  earlier  than  in  typhoid 
fever — as  early  as  during  the  first  febrile  days,  or  even  before  the 
beginning  of  the  initial  stage.  It  does  not,  as  a  rule,  persist  until  the 
beginning  of  defervescence,  and  for  that  reason  has  usually  disappeared 
almost  completely  in  fatal  cases  before  the  subject  comes  to  the  autopsy 
table.  In  several  instances  where  the  organ  was  at  first  perceptibly 
enlarged  I  failed  to  make  it  out  with  certainty  after  the  beginning  or 


SYMPTOMA  TOLOa  Y.  527 

middle  of  the  seeond  week.      Cuses  in  whieh  a  perceptible  enlargement 
persists  beyond  the  period  of  defervescence  are  distinctly  rare. 

Occasionally,  mider  conditions  where  it  is  absent  in  other  acute  infec- 
tious diseases,  such  as  in  individuals  of  advanced  age  and  depraved 
bodily  condition,  I  have  found  no  jierceptible  enlargement  of  the  spleen 
either  at  the  beginning  or  during  the  entire  course  of  the  disease.  In 
examining  a  typhus  fever  patient  for  enlargement  of  the  spleen,  the 
only  reliable  method — palpation — is  rendered  somewhat  difficult  by  the 
fact  that  the  enlargement  rarely  exceeds  a  moderate  degree,  and  the  con- 
sistence of  the  organ  is,  on  the  average,  less  than  in  other  infectious 
diseases.  Sensitiveness  of  the  organ,  whether  passive  or  elicited  by 
pressure,  is  comparatively  rare. 

Among  70  patients  admitted  during  the  first  week  of  the  disease,  we 
failed  utterly  to  make  out  enlargement  of  the  spleen  by  palpation,  and 
made  out  a  doubtful  enlargement  by  percussion  in  17,  while  in  the  remain- 
ing cases  the  enlargement  was  made  out  usually  between  the  third  and  the 
fifth  day.  In  the  case  of  a  watchman  who  had  become  infected  in  the 
hospital,  a  large,  soft,  palpable  spleen  was  made  out  at  the  first  examina- 
tion, immediately  after  the  first  chill.  I  have  never  had  the  opportunity 
to  make  an  examination  during  the  period  of  incubation.  It  is  probable 
that  a  positive  result  would  often  be  obtained  at  this  time. 

The  external  lymph-glands,  like  the  mesenteric  and  bronchial  glands 
(see  Morbid  Anatomy),  are,  so  far  as  I  could  observe,  almost  always 
normal  in  uncomplicated  cases.  In  a  few  of  the  larger  epidemics — as, 
for  instance,  those  of  the  Crimean  war  and  of  the  Russian  campaign 
against  the  Turks — inflammatory  swelling  of  the  axillary  and  sometimes 
of  the  inguinal  lymph-glands  appears  to  have  been  somewhat  more 
common,  and  occasionally  to  have  ended  in  suppuration. 

CHANGES  IN  THE  SKIN. 

The  nomenclature  of  typhus  fever  (typhus  exanthematicus,  typhus 
petechialis,  spotted  fever,  febris  puerpera  epidemica,  morbus  pulicaris, 
morbus  puncticularis,  febris  peticularis,  etc.) '  shows  the  importance 
attributed  by  physicians  to  the  characteristic  changes  of  the  skin,  from 
the  earliest  times  when  typhus  was  considered  a  subvariety  of  typhoid 
fever,  to  the  present,  when  it  is  recognized  as  a  distinct  disease. 

The  Typhus  Bxanthem. — The  rash  is  indeed  sufficiently  pecu- 
liar in  the  manner  of  its  appearance  and  development,  its  character  and 
distribution,  to  be  counted  among  the  few  specific  and  diagnostically 
important  phenomena  of  the  disease. 

The  eruption,  as  we  have  seen,  most  frequently  appears  on  the  fourth 

1  See  Murchison,  who  gives  nineteen  names  of  the  disease,  all  of  which  refer  to 
the  skin-eruption. 


528  TYPHUS  FEVER. 

or  fifth  day  of  the  disease.      It  may  appear  on  the  sixth  or  seventh,  or 
as  early  as  the  seeotid  day. 

The  time  of  its  ap{)earaiiee  varies  in  different  localities  and  in  different 
epidemics.  In  Berlin,  in  1878,  I  fonnd  that  the  eruption  appeared  early — 
on  the  second,  third,  or  fourth  day;  whereas,  in  the  epidemie'of  187!),  the 
erup.tion  occurred,  usually  later — on  the  fourth,  fifth,  or  as  late  as  the  seventh 
day.  I  suhjoin  a  tahle  from  an  article  by  niy  assistant,  Salomon.  In  39 
cases  during  the  epidemic  of  1879,  where  the  linie  of  appearance  could  he 
accurately  noted,  it  was  found  to  be  as  follows  : 

Day  of  tlie  clisease.  Cases.    Day  of  the  disease.  Cases. 

Second 2  Sevciitli  ...        6 

Third 4      -  Ei-htli 2 


Fourth 11 

Fifili 13 

Sixth 0 


Nintli      1 

Tenth"    0 

Eleventh    1 


Murchisou  gives  the  fourth  day  as  the  average  time  of  appearance  of  the 
eruption,  and  ex|>ressly  states  that  he  rarely  saw  it  appear  later  than  the 
fifth  day. 

Cases  in  which  the  eruption  is  reported  to  have  been  delayed  until  the 
beginning  of  the  second  week,  or  even  until  the  twelfth  or  the  fourteenth 
day,  must  be  accepted  with  great  caution.  That  a  very  late  appearance  is 
possible  is  proved  by  the  case  in  our  table,  that  was  distinguished  by  the 
appearance  of  the  roseola  on  the  eleventh  day,  without  presenting  any  other 
peculiarity  in  the  course  of  the  disease. 

AMth  its  first  appearance  the  eruption  comes  out  all  at  once  in  a 
single  crop,  so  that  the  ultimate  extent  is  usually  complete  within  forty- 
eight  hours.  It  is  very  rare,  in  my  experience,  that  the  duration  of 
the  eruption  lasts  longer  than  this.  A  second  crop,  or  the  disappearan(^e 
of  the  earliest  spots  and  the  appearance  of  a  new  crop,  is  practically 
unknown,  and  we  thus  have  an  important  diagnostic  point  differen- 
tiating the  roseola  of  typhus  from  that  of  typhoid  fever. 

In  regard  to  the  topography  of  the  eruption,  the  first  spots  in  cases 
that  I  was  able  to  observe  from  the  beginning  usually  appeared  on  the 
lower  abdomen  and  about  the  back  and  shoulders,  and  almost  at  the 
same  time,  but  less  thickly  at  first,  the  spots  ap])eared  on  the  chest  and 
upper  abdominal  region.  Very  soon  they  appear  on  the  extremities, 
while  those  on  the  trunk  continue  to  increase  in  number.  Not  rarely 
the  extremities  are  covered  at  the  same  time  as  the  trunk.  Ou  the  fore- 
arms the  spots  usually  appear  first  on  the  flexor  surfaces,  and  immedi- 
ately afterward  on  the  dorsal  surfaces,  down  to  the  back  of  the  hand. 
On  the  legs  the  eru]]tion  apjiears  as  far  down  as  the  dorsum  of  the  foot, 
where  it  is  often  veiy  conspicuous.  In  typical  cases  the  eruption  is 
least  marked  on  the  thigh,  especially  on  the  anterior  surface. 

This  distribution  of  the  eruption  presents  a  marked  difference  from 


SYMPTOM  A  TOL  0  (J  Y.  529 

that  seen  in  typhoid  fever,  where  the  rose-spots  b(!Conie  less  abundant 
the  farther  the  parts  are  removed  from  the  trunk.  Jiose-spots  on  the 
forearms  in  typhoid  are  so  rare  as  to  be  ahnost  a  curiosity,  and  I  have 
never  seen  them  as  far  down  as  the  dorsum  of  the  loot. 

The  faee  usually  escapes,  or  at  least  is  but  sparingly  attacked  by  the 
typhus  eruption.  A  few  spots  may  be  found  on  the  faces  of  women  and 
children  or  individuals  with  fair,  tender  skin.  On  the  other  hand,  the 
face  is  almost  always  flushed,  especially  in  the  beginning,  and  is  often 
distinctly  edematous. 

The  assertion  that  the  rash  of  typhus  differs  from  that  of  typhoid 
in  the  greater  abundance  of  the  lesions  is  true  only  in  a  general  sense. 
It  is  quite  true  that,  ex;cept  in  certain  cases  in  which  the  eruption  is 
particularly  abundant  on  the  trunk,  the  number  of  rose-spots  in  typhoid 
fever  does  not  nearly  equal  that  observed  in  many  cases  of  typhus, 
where  both  the  trunk  and  the  extremities  are  so  thickly  covered  that  the 
name  "  spotted  fever  "  appears  to  be  entirely  justifiable.  On  the  other 
hand,  there  are  not  a  few  cases  of  typhus  in  which  the  eruption  is  very 
faintly  developed  and  can  be  found  only  after  a  careful  search,  and 
between  these  two  extremes  we  meet  a  number  of  gradations,  both  as 
regards  the  number  and  the  distribution  of  the  spots.  There  can  be 
no  doubt  that  eases  occur  also  that,  in  analogy  to  similar  conditions 
in  the  acute  exanthemata,  might  be  designated  as  febris  exanthematica 
sine  exanthemate.  They  must,  however,  be  distinguished  from  cases 
in  which  the  eruption,  which  may  be  fairly  abundant,  is  completely 
obscured  by  dirt,  pigmentation,  parasitic  eruptions,  scratch-marks,  etc. 

As  regards  the  development  and  special  character  of  the  eruption, 
three  distinct  stages  may  be  observed  in  a  fully  developed  case  :  The 
stage  of  simple  hyperemia  ;  the  stage  during  which  hemorrhagic  changes 
begin ;  the  stage  of  pronounced  petechial  appearance. 

A  fresh  typhus  fever  spot  appears  as  a  pale-red  macule,  ranging  in 
size  from  that  of  a  pin-head  to  that  of  a  lentil,  rarely  larger,  with  ill- 
defined  outlines  (Plate  I.,  Fig.  1),  which,  as  may  be  best  determined  by 
means  of  the  glass  pleximeter,  disappears  completely  on  pressure,  and 
is  therefore  at  first  of  a  purely  hyperemic  nature.  In  young  individuals 
with  tender  skin  a  few  or  a  majority  of  the  macules  are  at  first  slightly 
elevated.  In  contrast  to  the  rose-spots  of  typhoid  fever,  which  are 
always  more  or  less  papular,  and  retain  that  character  as  long  as  they 
are  present,  the  serous  infiltration  in  typhus  fever,  if  present  at  all, 
is  always  much  less  pronounced  and  very  evanescent. 

The  macular  nature,  the  irregularity  and  indistinctness  of  the  out- 
lines, and  the  pale  color  of  the  spots  combine  to  make  it  exceedingly 
u 


530  TYPHUS  FEVER. 

difficult  to  demonstrate  tlie  eruption  during  the  first  purely  hyperemic 
stage.  A\'^bile  a  search  for  the  rose-spots  on  dark  skins  is  practically 
hopeless,  it  is  difficult  in  an  any  ease  to  recognize  the  eruption  with 
certainty  without  proper  illumination,  a  circumstance  that  causes  the 
greatest  trouble  to  hospital  residents  in  admitting  patients  during  the 
night. 

Occasionally,  the  eruption  stands  out  more  ])romincntlv  from  its  sur- 
roundings when  seen  at  a  slight  distance  than  at  close  range. 

In  not  a  few  cases  the  eruption  does  not  develop  beyond  the  first 
hy[)eremic  stage,  and,  after  persisting  for  several  days  or  longer,  dis- 
appears completely  without  leaving  the  slightest  trace  on  the  body  of 
the  convalescent,  or  on  the  cadaver  if  the  case  has  terminated  fatally. 

In  the  great  majority  of  cases  the  simple  hyperemic  stage  soon 
passes  away,  and  the  spots  become  darker,  of  a  coppery,  dirty-red  color, 
and  do  not  disappear  completely  on  pressure.  They  become  somewhat 
paler  when  the  pleximeter  is  applied,  but  the  central  portion  still  pre- 
sents a  dark-red  or  bluish  discoloration,  due  to  a  deposition  of  blood- 
pigment  (Plate  I.,  2).  This  deposition  begins  at  the  center  and  spreads 
to  the  periphery,  so  that  the  spots  sometimes  end  by  having  a  livid, 
bluish-red  color  and  undergoing  a  true  petechial  transformation.  If  the 
spots  are  abundant  and  widely  scattered  over  the  body,  the  appearance 
of  the  patient  becomes  absolutely  repulsive.  Such  cases  are,  however, 
exceptional.  In  most  patients  only  a  few  spots  undergo  petechial  trans- 
formation. The  eruption  presents  such  variations  in  the  nimiber  of 
lesions,  their  degree  of  development,  and  the  distribution  over  the  body, 
that  each  case  presents  a  different  appearanc;e. 

In  general,  it  may  be  said  that  the  hemorrhagic  spots  are  most 
numerous  near  the  large  folds  in  the  skin — in  the  inguinal  regions — 
and  on  the  dorsal  surfaces  of  the  body  ;  hence,  these  regions  should  be 
examined  with  particular  care  in  cases  in  which  the  nature  of  the 
eruption   is  doubtful. 

The  rose-spots  that  have  undergone  hemorrhagic  transformation 
must  be  distinguished  from  true  petechi£e  in  the  strict  dermatologic 
sense  of  the  word,  for  the  latter  appear  as  bluish-red  spots  due  to 
direct  hemorrhages  into  the  skin,  and  arc  not  preceded  by  a  hyperemic 
stage.  Such  true  petechiae  usually  appear  during  the  height  or  toward  the 
end  of  the  development  of  the  rash.  They  are,  however,  according  to 
my  experience,  comparatively  rare.  When  j^resent  in  small  numbers, 
they  are  of  no  significance.  When  they  are  abundant  the  prognosis  is 
bad,  especially  when  they  are  combined  with  extensive  hemorrhages 
into  the  skin  and  subcutaneous  tissue  and  cyanosis  of  the  face  and 


DESCRIPTION  OF  PLATES. 


PLATE  I. 

1.  Recent  typhus  fever  spots  of  not  more  than  twenty-tour  hours'  stand- 
ing, still  in  the  hyperemic  stage  ;  taken  from  the  abdomen  of  a  man  twenty- 
seven  years  of  age,  during  an  unusually  severe  attack  from  which  he  ulti- 
mately recovered.     The  rash  appeared  on  the  fourth  day  of  the  disease. 

2.  From  the  abdomen  of  the  same  patient.  Beginning  of  the  ninth  day 
of  the  disease. 

The  rose-spots  are  now  for  the  most  part  of  a  dark  livid  hue,  a  few  of 
them  rather  more  copper-colored,  owing  to  hemorrhagic  change. 

Scattered  among  the  rose-spots  are  a  few  recent  petechise,  and  at  one 
spot  (in  the  lower  right-hand  portion)  a  more  extensive  cutaneous  hemor- 
rhage. 

PLATE  H. 

3.  Compare  this  with  Plate  I.  Rose  spots  taken  from  the  abdomen  of 
a  woman  thirty -one  years  of  age,  suffering  from  typhoid  feve^\  Twelfth  day 
of  the  disease.  The  eruption  is  quite  copious,  and  some  of  the  lesions  are 
well  developed. 

The  three  pictures  were  made  by  the  author  at  the  bedside,  and  have 
been  faithfully  reproduced. 


SYMPTOMATOLOGY.  531 

extremities.  Patients  in  whom  this  phenomenon  is  present  as  a  rule 
present  a  horrifying  spectacle  on  account  of  the  hemorrhages  into  the 
conjunctivse  and  the  dark,  livid  appearance  of  the  rose-spots.  Such 
patients  but  rarely  recover. 

Occasionally,  especially  in  alcoholic  males  in  impaired  physical  con- 
dition, the  legs  and  dorsal  aspects  of  the  feet  are  covered  with  numerous 
petechise,  occupying  the  region  of  the  hair-follicles  or  the  hair-follicles 
themselves.  This  phenomenon  has  no  more  prognostic  significance  than 
the  cachectic  condition  that  is  at  the  bottom  of  it. 

It  is  a  well-known  fact  that,  in  times  of  epidemic,  patients  suffering 
from  any  febrile  condition  and  presenting  small,  circumscribed  cuta- 
neous hemorrhages,  pyemic  skin  emboli,  purpura,  flea-bites,  and  the 
like,  have  been  frequently  sent  to  the  hospitals  as  typhus  fever  patients 
by  physicians  of  limited  experience. 

As  in  other  acute  exanthemata,  especially  variola,  but  not  with  the 
same  frequency,  the  appearance  of  the  eruption  in  typhus  fever  may  be 
accompanied  or  immediately  preceded  by  a  diffuse  macular,  purely 
hyperemic  redness  of  the  skin,  especially  on  the  back,  chest,  and  neck. 
This  phenomenon  is,  however,  very  evanescent,  and  usually  disappears 
by  the  end  of  the  first  day  of  the  eruption. 

In  a  few  cases,  especially  in  persons  with  a  soft,  white  skin,  I  have 
seen  the  true  eruption  accompanied  or  immediately  preceded  by  the 
appearance  of  a  peculiar  large  macular,  "  measley  "  eruption,  occupying 
chiefly  the  forearms  and  backs  of  the  hands ;  this  eruption  rapidly  dis- 
appears, and  continues  to  recur  for  a  short  time  at  the  same  place. 

The  duration  of  the  true  typhus  eruption  and  the  duration  of  the 
individual  stages  appear  to  vary  in  the  different  epidemics  and  to  some 
extent  in  different  individuals.  The  average  duration  for  severe  and 
moderately  severe  cases  may  be  given  as  from  seven  to  ten  days ; 
traces  of  the  hemorrhagic  eruption,  in  the  form  of  pale-brown  or 
greenish-yellow  spots,  may,  however,  persist  beyond  that  time  and 
continue  during  convalescence. 

The  primary,  purely  hyperemic  rose-spots  last  a  very  short  time. 
If  they  fail  to  undergo  hemorrhagic  change,  they  usually  disappear  on 
the  first  or  second,  or,  at  the  latest,  on  the  third  day.  If  the  hemor- 
rhagic change  is  only  partial,  the  macules  may  not  be  visible  after  five 
or  six  days. 

Like  many  other  phenomena  of  the  disease,  the  abundance  and 
degree  of  development  of  the  eruption  depend,  among  other  things,  on 
the  character  of  the  epidemic.  In  some  epidemics,  according  to  reliable 
authors,  they  are  of  slight  extent ;  whereas,  on  the  other  hand,  epidemics 


532  TYPHUS  FEVER. 

have  been  describetl  that  were  distinguished  by  tlie  uuusual  abundance 
and  pronounced  character  of  the  cutaneous  changes.  Age  does  not,  so 
far  as  I  have  observed,  appear  to  affect  the  abundance  of  the  eruption. 
Contrary  to  the  experience  of  Murchison,  Griessinger,  Ebstcin,  Bese, 
and  Wyss,  1  have  seen  the  eruption  (^uite  as  profuse  in  children  as  in 
adults,  and  Filatow ^  appears  to  lune  observed  the  same. 

Judging  from  my  own  experience,  there  apjicars  to  be  no  distinct 
relation  between  the  abundance  of  the  eruption  and  the  severity  of  the 
disease.  I  have  seen  the  most  severe  fatal  cases  with  little  or  no  erup- 
tion, and,  conversely,  I  have  frequently  observed  the  same  condition  in 
very  mild  cases.  I  am  well  aware  that  I  am  at  variance  in  this  view 
with  that  of  ]\lurchison,  Griessinger,  and  many  of  the  older  authors 
(Rasori,  Henderson,  and  Stuart). 

In  addition  to  the  specific  changes  so  far  described,  there  are  many 
other  cutaneous  phenomena  that  deserve  notice. 

Among  the  more  important  is  the  appearance  of  miliaria  crystal- 
lina  in  the  middle  or  at  the  end  of  the  second  week,  from  one  to  three 
days  before  the  beginning  of  defervescence.  The  eruption  is  often  very 
abundant  on  the  chest  and  abdomen,  and  is  more  frequent  in  younger  than 
in  older  individuals,  rarely  occurring  after  the  forty-fifth  year.  The 
contents  of  the  vesicles  in  all  the  cases  examined  by  me  were  acid  or 
neutral  in  reaction,  never  alkaline. 

I  observed  miliaria  crystallina  in  abundance  m  from  6  per  cent,  to 
8  per  cent,  of  my  cases  in  the  years  1878  and  1879.  Other  authors 
give  a  much  higher  percentage,  while  Murchison,  on  the  other  hand^ 
states  that  the  symptom  is  rare. 

Whenever  they  were  well  developed,  the  sudamina  were  followed  by 
distinct  branny  desquamation  of  the  skm.  This  desquamation,  how- 
e^'er,  is  without  doubt  a  very  common  occurrence  during  the  period 
of  convalescence,  and  follows  the  specific  skin-eruption  as  well  as 
miliaria  crystallina.  It  affects  the  entire  skin,  iucludmg  such  portions 
as  were  not  covered  by  the  roseolous  eruption — as,  for  instance,  the  face. 
In  2  cases  during  convalescence  I  saw  a  shedding  of  the  epidermis  in 
large  scales,  such  as  are  usually  seen  in  scarlet  fever. 

There  is  a  marked  variation  in  the  statements  of  different  authors  in 
regard  to  the  occurrence  of  herpes  facialis.  Jacquot  saw  it  in  one- 
fifth  of  his  patients,  while  in  other  epidemics  it  was  altogether  absent 
(Hermann,  Petersburg,  1874-75).  I  believe  the  absence  of  herpes 
facialis  to  be  exceptional ;  it  is  certainly  fairly  frequent^ — much  more 
frequent  than  in  typhoid  fever.  In  1879  herpes  facialis  was  present  in 
'  Vorlesungen  uber  acute  Infektio7iskrank}i,elten  im  Klndesalter,  Wien,  1897. 


SYMPTOMATOLOGY.  533 

5.4  per  cent,  of  our  patients,  and  more  frequently  during  the  beginning 
of  the  disease  than  during  the  period  of  defervescence. 

In  a  number  of  cases,  during  the  second  week  of  the  disease,  I  saw 
a  moderately  severe  icterus,  without  marked  change  in  the  color  of 
the  stools.  These  cases  were  all  very  grave,  and  most  of  them  (4  out 
of  6)  terminated  fatally.  At  the  autopsies  no  changes  were  found  in  the 
larger  gall-passages  or  in  the  duodenum,  but  very  marked  cloudy  swell- 
ing was  present  in  the  liver. 

Cutaneous  abscess  and  furuncles  are  not  frequent.  They 
were  present  in  a  few  cases,  were  most  abundant  on  the  nates,  and 
occasioned  considerable  annoyance  to  the  patient  during  convalescence, 
which  was  prolonged  on  account  of  their  presence. 

Bed-sores  occurred  in  a  little  over  3  per  cent,  of  my  cases.  Dis- 
regarding cases  that  were  much  protracted  by  complications  and  sequels, 
the  condition  occurred  during  the  true  course  of  the  disease  only  in  very 
severe  cases,  but  in  these  the  sores  appeared  so  rapidly  and  were  so 
extensive  as  to  suggest  a  severe  trophic  disturbance  in  addition  to 
the  ordinary  pressure-eifects.  Occasionally,  they  were  combined  with 
abscesses  and  deep  ulcerations  undermining  the  subcutaneous  cellular 
tissue,  or  even  more  or  less  extensive  exfoliation  of  necrotic  bone, 
involving  the  sacrum  and  coccyx  and  even  the  scapulae. 

In  very  severe  cases,  especially  where  there  had  been  marked  hemor- 
rhagic changes  in  the  eruption,  slight  irregularities  in  the  bedding — 
wrinkles  in  the  sheets,  etc. — sufficed  to  produce  bluish-black  spots  and 
stripes  on  the  skin  of  the  back  and  buttocks  in  a  very  short  time,  and 
these  often  formed  the  nucleus  of  extensive  purulent  tissue-necrosis. 

Gangrene  may  be  observed  in  typhus  fever  in  certain  portions  of  the 
skin  not  exposed  to  pressure,  but  far  removed  from  the  center  of  circula- 
tion. For  obvious  reasons  this  does  not  occur  in  the  severest  forms.  Thus, 
I  have  seen  gangrene  of  the  tip  of  the  nose  and  ear,  and  very  fre- 
quently of  the  skin  covering  the  toes.  An  entire  toe  may  necrose  and 
necessitate  exarticulation.  Seliger  observed  gangrene  of  the  fingers. 
I  myself  have  never  seen  it,  and  other  authors  note  it  as  a  curiositv. 

Brysipelas,  which  in  the  older  writings  is  mentioned  as  a  frequent 
complication  of  typhus  fever,  has  become  very  rare,  oyving  to  the  favor- 
able conditions  prevailing  in  modern  hospitals. 

Noma  and  hospital  gangrene,  which  are  also  mentioned  in  the 
literature,  are  of  no  more  than  a  historic  interest  at  the  present  day. 

Certam  reliable  observers  (Murchison,  Lind,  Gerhard)  profess  to  have 
noticed  a  peculiar  odor  from  the  skin  of  typhus  fever  patients,  as  in  the 
case  of  the  other  acute  infectious  diseases,  especiaUj  the  exanthemata. 


534  TYPHUS  FEVER. 

The  odor  is  tloscribed  as  musty  or  as  "  mousey,"  and  is  said  to 
become  very  marked  when  the  patients  are  closely  crowded  :  this  is 
quite  to  be  expected.  AVhether  it  was  due  to  the  faultless  ventilation 
T  cannot  say,  but  I  never  noticed  any  s])ceific  exhalation  from  our 
patients  in  the  Moabit  lazaretto. 

THE    NERVOUS    SYSTEM   AND   ORGANS    OF    SPECIAL   SENSE. 

Disturbances  of  the  nervous  system  are  very  marked  from  the  begin- 
ning, and  later  they  form  the  predominant  feature  in  the  clinical  picture. 
They  are  so  conspicuous  that  typhus,  as  well  as  typhoid,  fever  was, 
until  after  the  middle  of  the  eighteenth  eentury,  identiiied  witli  "nerve- 
fever,"  or  at  least  regarded  as  one  of  its  subvarieties.  Except  in  very 
mild  Ccises  of  short  duration,  the  symptoms  referable  to  the  ner\ous 
system  during  the  entire  febrile  period,  and  in  severe  cases  during  the 
convalescent  period  as  well,  are  far  more  marked  and  persistent  than 
in  any  other  acute   infectious  disease,  not  excepting  typhoid  fever. 

The  clinical  phenomena  do  not  in  the  least  tally  \\\i\\  the  organic 
changes  found  in  the  central  nervous  system  by  our  present  methods 
of  research.  These  phenomena  are,  without  a  doubt,  due  much  more  to 
the  effect  of  the  toxin  than  to  the  rise  in  tem])erature  itself,  as  was 
fonnerly  believed,  since,  notwithstanding  a  rapid  rise  during  the  begin- 
ning of  the  disease,  there  are  no  corresponding  ner^^ous  phenomena 
at  this  period.  Quite  often  they  are  most  severe  during  and  after  the 
period  of  defervescence,  and  any  experienced  practitioner  will  recall 
cases  in  which  the  temperature  remained  low  throughout,  and,  neverthe- 
less, there  was  marked  delirium  or  coma-vigil. 

In  severe  and  moderately  severe  cases,  the  patients  complain,  on  the 
very  first  day,  of  such  great  lassitude  and  general  prostration  that  they 
immediately  go  to  bed.  None  but  the  very  mildest  cases,  and  these 
only  exceptionally,  remain  ambulatory  cases  throughout  their  entire 
course. 

Headache. — Almost  all  the  patients  in  the  beginning  complain 
of  headache,  which  persists  throughout  the  initial  period  until  the 
appearance  of  the  rash,  and  often  becomes  so  intense  as  to  mask  all 
the  other  symptoms.  The  pain  is  referred  to  the  vertex,  frontal  region, 
eyes,  and,  in  a  few  cases,  to  the  occiput,  radiating  down  into  the  neck 
and  shoulders.  Combined  with  the  headaclie  there  are  frequently  pres- 
ent vertigo,  pain  in  the  sacrum  and  limbs,  and  hyperesthesia  of  the 
finger-tips,  toes,  and  soles  of  the  feet,  which  many  patients  find  partic- 
ularly distressing. 

Psychic   Disturbances. — During  the  first  day  there  is  little  or 


SYMPTOMATOLOGY.  535 

no  disturbance  of  consciousness  even  in  severe  cases ;  tin;  j^atients  are 
dull  and  lethargic,  and,  although  restless,  lie  supine  on  their  backs.  In 
spite  of  the  great  prostration  most  of  the  patients  cannot  sleej)  day  or 
night;  if  they  do  fall  asleep,  tliey  are  immediately  roused  from  tlieir 
slumbers  by  terrifying  dreams.  These  consist  sometimes  in  peculiar 
sensations  recurring  again  and  again,  such  as  a  sensation  as  of  soaring, 
flying,  or  falling. 

At  this  period  the  mental  faculties,  even  in  these  very  severe  cases, 
are  still  well  preserved.  Although  they  are  dull  and  disinclined  to 
any  mental  or  bodily  activity,  the  patients  still  retain  consciousness  of 
their  surroundings.  When  spoken  to,  they  answer  slowly  and  in  broken 
phrases,  but,  on  the  whole,  correctly.  They  evidently,  however,  experi- 
ence some  difficulty  in  collecting  their  thoughts,  cannot  readily  compre- 
hend long  and  complicated  questions,  and  when  they  attempt  to  do  so, 
their  attention  soon  wanders,  their  thoughts  drift  into  other  channels, 
or  they  later  complain  of  a  marked  increase  of  the  jiain  in  the  head  and 
eyes. 

Toward  evening  and  during  the  night  dreams  and  hallucinations 
continue  to  haunt  them,  even  though  they  are  awake.  A  few  are 
violently  delirious,  even  at  this  early  period. 

It  is  only  in  the  milder  cases,  however,  and  in  moderately  severe 
cases  of  very  short  duration,  that  the  psychic  disturbances  are  confined 
to  these  narrow  limits  throughout  the  course  of  the  disease.  During  the 
second  half  of  the  first  week  most  patients  become  more  and  more  stupid 
and  confused  even  during  the  day.  As  their  mental  condition  becomes 
worse,  the  subjective  symptoms,  especially  the  headache  and  backache, 
subside,  and  by  the  end  of  the  first  or  the  beginning  of  the  second  week 
loss  of  consciousness  is  usually  complete  and  permanent.  With  eyes 
half-shut,  completely  cut  off  from  the  external  world,  the  patient  lies 
either  motionless  in  bed,  sunk  in  a  deep  apathy  and  muttering  to  him- 
self and  picking  at  the  bed-clothes  with  trembling  hands,  or  else 
gesticulates  wildly  and  cries  out  in  his  terror. 

The  patient's  behavior  during  this  stage  depends  on  various  external 
circumstances  and  on  individual  temperament.  In  some  patients  depres- 
sion is  most  prominent,  in  others  delirium,  making  its  appearance  in  the 
evening  and  lasting  the  entire  night,  sometimes  persisting  in  the  daytime. 
In  vigorous  young  individuals  the  delirium  often  partakes  of  the  nature 
of  violent  mania.  They  rage  and  cry  out,  jump  out  of  bed,  and  try  to 
escape  from  their  terrifying  hallucinations.  Sometimes  they  become 
intensely  aggressive  and  try  to  injure  their  attendants,  or  they  endanger 
their  own  lives  by  endeavoring  to  escape  through  the  window,  etc. 


536  TYPHUS  FEVER. 

Suicidal  attempts,  some  Avith  disastrous  result,  have  also  been  observed. 
Those  who  wore  in  an  inijxiired  state  of  heakh  before  the  beginning;  of 
the  diseiise  and  old  and  decrepit  patients  present  a  quieter,  more  mut- 
tering form  of  delirium  from  the  very  beginning  and  during  the  entire 
febrile  stage. 

In  most  cases  the  delirium  is  based  on  one  or  more  torturing  hallu- 
cinations ;  in  others  there  is  a  veritable  flight  of  ideas,  reducing  the 
patient  to  the  verge  of  exhaustion.  The  delusions  are  usually  of  a  sad- 
dening, depressing,  or  agitating  nature — delusions  of  death  or  disease 
affecting  friends  or  relatives,  of  persecution  and  personal  danger,  some- 
times under  the  most  remarkable  conditions,  such  as  flying  in  a  balloon, 
or  being  in  an  open  boat  on  the  high  seas,  etc.  In  other  cases  the 
hallucinations  are  connected  with  persons  or  objects  in  the  patient's 
immediate  vicinit}'.  These  hallucinations  may  assume  the  most  fantastic 
and  terrifying  forms,  or,  what  seems  to  me  more  frequent,  they  may 
refer  to  former  events  in  the  patient's  life,  to  his  occupation,  to  some 
fixed  habit,  or  to  his  vices  and  passions.  In  a  considerable  number  of 
cases  the  condition,  as  is  quite  frequently  proved  by  the  histoiy,  is  a 
simple  exacerbation  of  febrile  and  alcoholic  delusions. 

A  large  ward  full  of  typhus  fever  patients  offers  the  greatest  imag- 
inable contrasts,  and  the  confusion  arising  from  this  wild  medley  of 
feverish  groans  and  delirious  ravings  is  enough  to  shake  the  nerves  of 
the  steadiest  physician  ;  it  has  been  known  to  scatter  the  less  responsi- 
ble attendants  in  panic-stricken  flight. 

Almost  every  author  tells  of  peculiar  and  often  very  remarkable  hal- 
lucinations. Murchisoo,  Hildenbrand,  and  Guueau  de  Mussy  described 
their  own  very  ioterestiug  psychic  conditions  as  they  recalled  them  after 
recovery.  One  of  my  patients,  a  lawyer,  of  a  naturally  vivacious  tempera- 
ment, exhibited  during  the  fever  so  violent  an  antipathy  toward  his  attend- 
ant that  the  man's  life  was  in  danger.  After  his  recovery  he  remembered 
distinctly  the  details  of  the  terrifying  apparition,  and  described  how  the  man 
sometimes  appeared  to  have  enormously  long  arms  and  legs  or  else  inflated 
himself  to  frightful  ]iroportions,  or  sat  by  his  bed  without  any  head.  The 
apparition  was  so  frightful  at  one  time  as  to  induce  him  to  attack  the 
monster  with  a  knife,  as  he  himself  afterward  remembered.  Another  one 
of  my  patients,  an  old  sailor,  imagined  himself  for  days  together  in  a 
crow's-nest  during  a  violent  storm,  surrounded  by  huge  black  birds.  In 
many  patients  the  hallucinations  are  exceedingly  monotonous  and  repeat 
themselves  day  after  day.  We  had  a  scissors-grinder  in  the  ward  who  for 
days  and  days  would  repeat,  "  Have  ye  anything  to  grind  ?  "  and  a  coachman 
w'ho  was  continually  urging  on  his  horses  and  found  constant  occupation  in 
repairing  his  evidently  nuich  dilapidated  vehicle.  Another  of  my  patients, 
who  after  his  recovery  turned  out  to  be  a  clerk  with  hysteric  tendencies 
and  given  to  onanism,  imagined  himself  dead  and  translated  to  the  higher 
regions,  whence  he  could  look  down  on  his  dead  body  and  witness  the  prep- 


SYMPTOM  A  TOL  OG  Y.  537 

arations  for  his  own  funeral.  During  this  time  he  lay  in  a  muttering 
delirium  alternating  with  cataleptic  rigidity.  Delusions  of  death  and  of 
being  buried  alive  have  also  been  described  by  other  authors. 

The  onset  and  duration  of  the  delirious  stage,  like  the  expressions 
of  the  delirium  itself,  are,  of  course,  subject  to  many  variations.  In 
comparatively  rare  cases,  as  we  have  seen,  the  delirium  appears  during 
the  first  days  of  the  disease,  and  in  such  cases  the  prognosis  is  bad.  I 
remember  one  case  in  which,  with  a  rapid  rise  of  temperature,  furious 
delirium  declared  itself  before  the  end  of  twenty-four  hours ;  this  case 
ended  fatally  on  the  eighth  day. 

Much  more  frequently  the  delirium  appears  late  in  the  middle  or 
second  half  of  the  second  week,  or  it  may  in  rare  cases,  as  observed 
once  or  twice  by  myself,  be  delayed  until  a  day  or  two  before  the  begin- 
ning of  defervescence.  As  a  rule,  the  restlessness  reaches  its  highest 
degree  toward  the  end  of  the  first  or  the  beginning  of  the  second  week. 
After  that  the  patients  become  quieter,  the  insomnia,  which  up  to  this 
time  had  been  almost  constant,  begins  to  yield,  and  one  of  the  most 
delightful  events  at  this  time,  indicating  a  marked  change  for  the  bettor, 
is  a  long  and  restful  sleep. 

Other  patients,  again,  who  are  suffering  from  a  very  severe  form  of 
the  disease,  lose  their  restlessness  only  to  sink  into  deep  and  lasting 
coma,  which  in  the  great  majority  of  cases  ends  in  death  after  a  few 
days  or  sometimes  even  after  twenty-four  hours,  but  which,  after  per- 
sisting several  days,  may  end  in  recovery,  as  I  myself  have  seen "  in 
several  cases. 

Coma. — The  form  of  stupor  known  as  coma-vigil  is  of  the  worst 
possible  prognostic  significance.  The  patient  is  pale,  cyanotic,  with 
haggard  features  and  hanging  jaw,  eyes  wide  open  and  staring  into 
space ;  usually,  he  is  absolutely  impervious  to  external  influences, 
although  sometimes  the  sensorium  is  only  moderately  involved.  The 
external  skin  is  cool  and  covered  with  a  cold  perspiration,  while  the 
temperature  in  the  rectum  may  be  subnormal  or  even  febrile.  The 
extremities  are  icy  cold  and  cyanotic,  the  skin  covering  the  toes  and 
fingers  often  is  wrinkled,  and  the  limbs  are  either  flexed  and  motion- 
less or  in  a  constant  tremor  resembling  subsultus  tendinmn  with  car- 
phology.  The  tremor  sometimes  reaches  so  intense  a  degree  as  almost 
to  warrant  being  called  a  convulsion.  Whether  the  edema  of  the  pia 
found  at  the  autopsy  has  anything  to  do  with  it  is  a  question  that  is 
still  open  for  investigation.  Add  to  this  that  the  respirations  for  days 
may  be  invisible,  that  the  pulse  cannot  be  felt,  and  that  the  heart- 
sounds  are  barely  audible,  and  it  can  readily  be  understood,  especially 


538  TYPHUS  FEVER. 

if  the  extremities  are  free  from  tremor,  that  the  transition  from  such 
very  faint  manifestations  of  life  to  actual  death  often  occurs  almost 
impereeptihly. 

Sensory  Disturbances. — For  obvious  reasons  but  little  is  known 
regarding  the  disturbances  of  sensation  tluring  the  disease,  especially 
during  the  febrile  stage. 

The  distressing  symptoms  of  the  first  stage,  such  as  pains  in  the 
toes,  fingers,  and  thighs,  radiating  to  the  popliteal  space,  which  subside 
during  the  period  of  stujior  and  coma,  often  reappear  as  consciousness 
is  re-established,  and  c<Mitinuc  to  annoy  many  patients  up  to  the  time 
of  convalescence. 

Severe  neuralgic  pains  in  certain  nerve-tracts  occasionally  appear 
during  the  time  of  defervescence.  These  neuralgic  pains  arc  quite  com- 
mon, but  fortunately  subside  after  a  comparatively  short  time  without 
any  special  treatment.  The  nei'ves  of  the  lower  extremities,  especially 
those  of  the  feet  and  toes,  are  attacked  with  predilection ;  but  I  have 
also  known  the  sciatic  nerve  to  be  affected.  The  distribution  of  the 
brachial  plexus  is  more  rarely  attacked.  Whether  or  uot  it  is  a  mere 
accident  I  am  miable  to  say,  but  as  regards  the  trigeminus,  I  saw  only 
supra-orbital  neuralgia,  and  but  6  cases  of  that,  in  my  experience  in 
Moabit  in  1878  and  1879. 

Anesthesia  confined  to  approximately  the  same  regions  as  the  neu- 
ralgia, though  more  rare,  has  been  observed  also.  The  attacks  of  anes- 
thesia are  likely  to  last  longer  than  those  of  neuralgia.  I  have  known 
anesthesia  of  an  area  on  the  thigh  as  large  as  the  palm  of  the  hand  to 
persist  for  three  months  after  recovery,  and  a  similar  one  in  the  dis- 
tribution of  the  ulnar  nerve  to  persist  two  months  after  recovery. 

Motor  Disturbances. — Among  general  motor  disturbances  we 
may  mention  a  more  or  less  extensive  tremor,  which  is  almost  always 
present  at  the  height  of  the  disease  in  severe  and  moderately  severe 
cases.  Most  frequently,  it  is  confined  to  the  forearms  and  hands ;  at 
other  times  it  aifects  the  trunk  and  the  four  extremities  equally,  and 
in  such  a  degree  as  to  suggest  to  the  observer  genuine  convulsive  or 
choreic  contractions,  and  this  may  possibly  account  for  the  fact  that 
some  authors  have  reported  general  convulsions  and  St.  Vitus'  dance 
as  occasional  complications  of  typhus  fever.  It  is  worth  noting  that 
any  external  motion  when  the  patient  is  conscious  or  semiconscious,  or 
any  change  in  the  delusion  when  the  patient  is  comatose,  is  followed 
by  marked  aggravation  of  the  tremor,  just  as  in  the  case  of  a  true 
intention-tremor. 

In  many  patients  the  muscular  unrest  assumes  the  character  of  sub- 


SYMPTOMATOLOGY.  539 

sultus  tendinum  with  carphology.  All  these  convulsive  phenomena  are 
much  more  common  and  more  violent  during  the  height  of  a  typhus 
fever  attack  than  they  are  in  typhoid  fever. 

True  general  and  partial  convulsions  are  comparatively  rare.  If 
they  occur  at  all,  they  do  so  in  young,  excitable  individuals  (jr  in  alco- 
holics, usually  in  the  middle  or  toward  the  end  of  the  second  week  (^f 
the  disease,  and  they  are,  as  a  rule,  of  bad  prognostic  significance.  Ilie 
patients  may  pass  away  in  a  convulsive  attack  or  they  may  live  for  a 
few  days  afterward,  during  which  they  remain  in  deep  coma,  with  or 
without  a  return  of  the  convulsions.  Although  these  attacks  present 
the  general  picture  of  eclampsia,  and  are  often  accompanied  by  albu- 
minuria and  nephritis,  it  has  not  as  yet  been  satisfactorily  determined 
whether  they  are  to  be  regarded  as  uremic  in  character.  I  have  seen 
violent  convulsions  in  2  cases,  one  of  which  was  entirely  free  from 
albuminuria,  and  the  other  showed  but  very  small  amounts  of  albumin 
in  the  urine. 

Partial  convulsions  are  distinctly  more  rare.  The  best  marked  case 
that  I  have  seen  was  one  in  a  writer,  nineteen  years  of  age,  in  whom 
the  convulsions  were  confined  to  the  right  lower  half  of  the  face  and 
the  right  upper  arm ;  this  case  terminated  favorably. 

Tetanus  and  conditions  resembling  trismus  are  occasionally  men- 
tioned in  the  literature.  They  have  not  come  under  my  personal 
observation. 

On  the  other  hand,  I  have  seen  tonic  contractures  in  individual  mus- 
cle groups,  as,  for  instance,  in  the  flexors  of  the  forearm,  keeping  the 
hand  convulsively  clenched  for  days  at  a  time,  and  once  in  the  form  of 
obstinate  contraction  of  the  left  biceps,  causing  forced  flexion  of  the  fore- 
arm on  the  arm. 

A  few  of  the  patients  under  my  observation  were  much  depressed 
during  their  period  of  convalescence  by  repeated  daily  attacks  of  painful 
cramps  in  various  muscles  and  muscle  groups  following  sudden  move- 
ments in  these  parts.  The  muscles  chiefly  affected  were  those  of  the 
calf  of  the  leg,  individual  muscles  of  the  back  and  abdomen,  and  the 
muscles  of  the  forearm.  One  patient  would  be  attacked  by  cramps  in 
various  parts  of  the  body  at  the  same  time,  following  such  slight  move- 
ments that  for  days  together  he  did  not  dare  to  move.  These  cramps 
had  no  prognostic  significance  and  disappeared  after  the  patient  recovered. 

Distinct  cataleptic  conditions,  which  for  convenience  are  refen'ed  to 
at  this  point,  are  not  frequent,  although  a  more  or  less  pronounced 
tendency  to  cataleptic  rigidity  is  not  at  all  rare.  It  has  been  observed 
chiefly  during  the  height  or  in  the  second  half  of  the  febrile  stage, 


540  TYPHUS  FEVER. 

rarely  earlier,  aud  is  usually  associated  with  stupor  or  coma-vigil.  As 
these  conditions  often  make  the  clinical  picture  aj)pcar  much  worse  than 
it  is,  it  is  important  for  the  practitioner  to  become  thoroughly  familiar 
with  them. 

Palsies  referable  to  anatomic  alterations  are  rare — certaiuly  not  more 
common  than  in  typhoid  fever  or  in  small-pox  and  other  acute  exan- 
themata. 

Hemiplegia  has  been  described  in  various  epidemics  (Gourvier, 
Hampeln).  One  ease  of  the  kind  was  observed  among  our  patients  in 
the  epidemic  of  1879.  They  appear  to  be  de])endent,  as  shown  by 
some  of  the  autopsies,  on  hemorrhages  into  the  meninges  or  into  the 
substance  of  the  brain,  more  rarely  on  embolism  or  thrombosis  of  the 
larger  arteries  of  the  cerebrum,  and  Plampeln  described  one  case  of 
thrombosis  of  the  left  middle  cerebral  artery. 

Associated  with  these  conditions  we  find  palsies  of  single  extremities 
combined  often  with  disturbances  of  sensation — anesthesia,  paresthesia, 
etc.  One  case  of  partial  paralysis  of  the  entire  right  leg  (during  the 
epidemic  of  1878),  which  at  first  was  combined  with  hyperesthesia  and 
later  with  formication,  and  which  during  the  period  of  convalescence 
developed  into  a  well-marked  monoplegia,  I  am  now  inclined  to  regard 
as  a  nem'itis,  as  I  find,  by  reference  to  my  notes,  that  it  was  later  fol- 
lowed by  pronounced  muscular  atrophy.  It  would  be  both  interesting 
and  profitable  to  examine  by  modern  methods  such  cases  of  monoplegia 
in  future  epidemics,  to  see  whether  the  majority  are  not  due  to  neuritis. 

Meningitis. — Inflammation  of  the  cerebral  and  spinal  meninges 
occurs  with  varying  frequency  in  the  different  periods  and  epidemics. 
The  most  experienced  physicians  (Murchison,  Peacock,  Jenner,  Jaquot, 
Barallier)  absolutely  deny  the  occurrence  of  meningitis  in  typhus  fever. 
Moering  ^  also,  during  the  Crimean  epidemic,  was  unable  to  discover 
any  inflammation  or  suppuration  in  the  meninges  of  200  cases,  even 
though  a  careful  microscopic  examination  w^as  made.  Hampeln,  never- 
theless, reports  4  fatal  cases  of  purulent  meningitis  out  of  a  total  of  726 
patients  in  the  epidemic  of  Riga. 

DISTURBANCES  OF  THE  SPECIAL  SENSES. 
Bye  Disturbances. — The  eyes,  as  we  have  seen,  are  almost  always 
involved  to  a  slight  degree,  there  being  a  marked  injection  and  an  increased 
secretion  of  the  conjunctivre.  This  conjunctival  catarrh,  which  very  much 
resembles  that  which  occurs  in  measles,  in  some  instances  appears  during 
the  stage  of  incubation,  associated  with  corj^za.     With  the  beginning  of 

1  Quoted  by  Murchison. 


SYMPTOMATOLOGY.  541 

the  febrile  period  in  the  greut  majority  of  cases  the  catarrh  becomes  so 
marked  as  to  be  of  coiisidcrabk'  (hagnostic  importance,  since  this  stage 
presents  so  little  else  that  is  characteristu;.  Ln  severe  cases,  in  which  the 
patients  He  with  eyes  open  or  half-open  and  the  conjunctival  reflex  is 
very  inactive,  the  condition  not  rarely  leads  to  the  formation  of  super- 
ficial corneal  ulcers.  The  deeper  layers  of  the  cornea  but  rarely  become 
diseased,  although  I  have  myself  seen  one  case  of  extensive  parenchy- 
matous keratitis,  and  in  very  severe  epidemics  instances  have  been 
reported  of  necrotic  keratitis  with  perforation  of  the  cornea,  and  even 
panophthalmitis,  conditions  that,  fortunately,  did  not  occur  in  any  of 
my  cases.  These  conditions  appear  to  be  confined  to  forms  of  the  disease 
in  which  coma-vigil  is  a  prominent  feature. 

Hemorrhages  into  the  conjunctivae  are  quite  common  in  severe  cases, 
especially  in  alcoholic  subjects.  When  both  eyes  are  affected  and  the 
hemorrhage  is  extensive,  the  patient's  appearance  is  absolutely  uncanny, 
although  the  process  is  of  no  special   significance   to   the  eye  itself. 

From  the  beginning  of  the  disease  the  pupils  present  nothing  char- 
acteristic, but  later,  especially  in  severe  cases,  they  often  become  mark- 
edly contracted,  and  when  the  contraction  is  extreme,  the  appearance 
of  the  face  in  persons  with  light-colored  irides  becomes  quite  peculiar. 
How  this  phenomenon  is  produced  is  not  known,  although,  obviously,  it 
cannot  be  the  result  of  accident. 

In  regard  to  the  changes  of  the  refractive  media  and  of  the  eye- 
ground,  we  have  very  little  definite  knowledge.  It  is  true  that  we  find 
mention  of  the  occurrence  of  vitreous  opacities,  choroiditis,  iritis,  and 
optic  nerve  atrophy  in  special  text-books,  but  in  these,  unfortunately,  the 
distinction  between  typhus  and  typhoid  fever  is  not  always  sufficiently 
clear.  The  muscles  of  the  eyeball  are  rarely  involved.  In  2  cases  I 
saw  strabismus  develop  in  the  course  of  the  febrile  stage,  and  disappear 
after  recovery  was  established.  Other  authors  have  mentioned  spasms 
of  the  individual  muscles  of  the  eye  and  of  the  levator  palpebrum, 
followed  by  ptosis. 

Disturbances  of  the  Hearing-. — In  contradistinction  to  what  is 
observed  in  typhoid  fever,  interference  with  the  sense  of  hearing  due 
to  the  toxic  effect  on  the  auditory  center  in  the  brain  or  on  the 
auditory  nerve  appears  to  be  rare  in  typhus  fever.  My  own  experience 
compels  me  to  contradict  Lebert's  statement  that  the  hearing  becomes 
affected  toward  the  end  of  the  first  or  at  the  beginning  of  the  second 
week. 

As  a  rule,  auditory  disturbances  do  not  make  their  appearance  until 
the  period  of  convalescence,  when  they  become  comparatively  frequent. 


542  TYPHUS  FEVEIi. 

They  are  usually  due  to  swelling  of  the  mucous  membrane  lining  the 
Eustachian  tubes,  and  to  catarrh  of  tlie  tympanum,  ending  sometimes  in 
purulent  otitis  media  witli  perforation  of  the  tympanic  membrane  or 
even  in  inflammatory  disease  of  the  labyi'inth.  Occasiouall\-,  tlie  con- 
dition goes  on  even  to  purulent  intiltration  of  the  mastoid  cells  with 
periostitic  abscesses,  necessitating  surgiad  interference. 

These  morbid  changes  all  depend  on  the  hyperemia  and  swelling  of 
the  nuicous  membrane  of  the  uose  and  nasopharynx  that  are  jieculiar  to 
typhus  fever,  and  develop  during  the  first  days  of  the  disease. 

According  to  my  experience  in  Moabit,  they  usually  end  favorably. 
Most  patients  were  entirely  free  from  auditory  disturbances  when  they 
were  discharged. 

These  remarks  on  diseases  of  the  ear  are  based  principally  on  the  inves- 
tigatious  made  by  Hartniann  '  on  my  patients  in  Moabit  in  1879.  These 
investigations  appear  to  be  the  most  accurate  and  most  complete  that  have 
appeared  on  this  subject  up  to  the  present  time. 

Among  130  men  whom  he  examined  during  the  period  of  convalescence, 
Hartmann  found  aural  diseases  in  42,  or  32.3  per  cent.  His  table  is  as 
follows  : 

Accumulatii)ii  of  cerumen  in  tlie  external  auditoiy  meatus 6 

Swelling  of  the  tuLes  with  catarrh  of  the  tympanic  cavity 14 

Acute  inflammation  of  the  tympanic  cavity  without  perforation  of  the  memhrane  .      4 
Acute  inflammation  with  perforation  of  the  tympanic  membrane  (6  cases  were  uni- 
lateral, 3  bilateral ;  2  cases  were  complicated  with  periostitis  of  the  mastoid 
process,  1  case  with  exuberant  granules  in  the  external  auditory  meatus)  ...      9 
Aggravation  of  tinnitus  aurium  and  difficult  hearing  present  before  the  disease  .    .      3 

Recurrence  of  an  old  otorrhea       1 

Tinnitus  aurium  without  objective  flndings 2 

Diseases  of  the  labyrinth 3 

42 

Nothing  definite  is  known  of  any  deeper  alterations  in  the 
nose  than  the  typical  catarrhal  affection  already  mentioned. 

The  occurrence  of  epistaxis  during  the  first  stage  of  the  disease,  and 
even  before  the  beginning  of  the  fever,  is  worth  noting. 

CHANGES    IN    THE    RESPIRATORY  ORGANS. 
The   various   parts  of   the   respiratoiy   tract   all   ])articipate   in   the 
morbid  process  of  typhus  fever. 

The  catarrh  that  affects  the  nose  and  nasopharynx  spreads  uninter- 
ruptedly to  the  larynx,  trachea,  and  to  the  coarser,  as  well  as  the  finer, 
ramifications  of  the  bronchi. 

This  catarrh  of  the  respiratory  tract,  especially  the  bronchitis,  is  to 
be  regarded  not  as  a  complication,  but  as  a  jieculiar  manifestation  of 
1  Zeitschr.  f.  Ohrenh.,  Bd.  viii.,  H.  3. 


SYMPTOMATOLOGY.  543 

typhus  fever.  It  can  generally  be  discerned  during  the  very  first  days 
of  the  disease,  reaches  its  greatest  intensity  and  widest  distribution 
throughout  the  bronchial  tree  during  the  height  of  the  morbid  process, 
and  begins  to  subside  with  the  commencement  of  defervescence. 

Tracheobronchitis. — The  inflammation  of  the  trachea  and  bronchi 
is  accompanied  from  the  very  beginning  by  frequent  cough,  with  but 
slight  expectoration.  In  fact,  the  cough  is  accompanied  by  very  slight 
expectoration  during  the  entire  disease.  This  irritative  cough  is  par- 
ticularly distressing  during  the  early  stages,  on  account  of  the  acute 
aggravation  of  the  headache  that  it  occasions. 

I  have  seen  slight  traces  of  blood  in  the  scanty,  glairy  expectoration 
following  severe  paroxysms  of  coughing,  although  not  a  trace  of  any 
tuberculosis  was  present  even  then  or  later.  The  presence  of  a  trace 
of  blood  is  readily  accounted  for  when  one  remembers  the  extraordinary 
swelling,  maceration,  and  intense  reddening  of  the  respiratory  mucous 
membrane  so  often  observed  at  the  autopsy. 

The  atelectatic  conditions — lobular  pneumonia  and  hypostatic  con- 
gestions of  the  lower  lobe — are  undoubtedly  dependent  on  the  catarrh 
of  the  finer  bronchioles  and  the  cardiac  weakness  that  is  present  in  all 
severe  cases.  Hypostatic  congestion  usually  begins  to  develop  between 
the  tenth  and  fourteenth  days  of  the  disease,  at  the  time  of  greatest 
prostration — rarely  earlier  or  later — and,  as  in  all  acute  infectious  dis- 
eases, it  is  of  exceedingly  unfavorable  prognostic  significance.  As 
I  have  mentioned  in  a  former  section,  it  is  never  absent  in  the 
cadavers  of  typhus  fever  patients. 

The  older  authors  lay  great  stress  on  the  occurrence  of  diphtheric 
aflPections  of  the  respiratory  tract  both  in  the  nose  and  nasopharynx  and 
down  to  the  finest  ramification  of  the  bronchi.  They  occur  especially 
in  severe  and  extensive  epidemics. 

We  observed  this  condition  in  5  cases  in  1878  and  1879,  and  in  all 
the  result  was  fatal.  In  3  of  the  cases  tracheotomy  was  performed,  but  the 
patients  succumbed,  as  the  process  had  extended  into  the  most  minute 
ramifications  of  the  bronchi.  Whether  these  deposits  are  mere  diphtheric 
membranes  in  the  anatomic  sense,  or  whether  they  are  to  be  referred  to  the 
Klebs-Loffler  bacillus,  is  a  question  for  future  investigators  to  decide. 

Among  other  severe  and  unportant  diseases  of  the  respirator}^  tract 
those  affecting  the  larynx  deserve  particular  mention,  as  they  afford  the 
best  explanation  for  the  varying  frequency  of  certain  morbid  phenomena 
in  different  epidemics  and  the  different  periods. 

Murchison,  with  his  wide  experience  and  the  extensive  literature  at 
his   disposal,  does   not  appear  to   have  investigated  this  subject   very 


544  TYPHUS  FEVER. 

thoroughly.  He  only  mentions  in  passing  the  occurrence  of  erysipelatous 
disease  of  the  larynx.  According  to  my  own  experience,  the  character 
of  the  individual  epidemic  plays  an  im])ortant  part  in  this  matter. 
While  in  1878  we  had  scarcely  any  severe  laryngeal  infections,  their 
number  was  absolutely  terrifying  in   1879. 

Changes  in  the  I^arynx. — The  laryngeal  examination  is,  for 
obvious  rciisous,  \ery  difficult  and  cannot  often  be  carried  out.  When 
it  is  possible,  however,  the  cause  of  the  hoarseness  obser\ed  during  tiie 
first  week  is  found  to  be  a  simple  catarrhal  condition,  redness  and 
maceration  of  the  ventricular  bands,  with  discoloration  of  the  vocal 
cords  and  marked  swelling  of  the  mucous  membrane  covering  the 
arytenoid  cartilages.     Slight  erosions  are  also  occasionally  perceptible. 

These  changes  usually  disappear  comjiletely,  and  the  voice  during 
convalescence,  while  weak,  is  perfectly  clear  or  at  most  very  slightly 
hoarse. 

In  a  certain  number  of  cases,  on  the  other  hand,  the  initial  stages 
are  followed  by  more  profound  alterations  in  the  larynx,  which,  either  in 
themselves  or  from  the  consequences  that  follow  in  the  remaining  por- 
tions of  the  respiratory  tract,  may  be  of  the  gravest  significance. 

These  more  severe  changes  become  manifest  during  the  height  or 
toward  the  end  of  the  febrile  period,  and  appear  to  take  their  origin  in 
erosions  and  fissures  of  the  posterior  laryngeal  wall. 

These  defects  are  due  directly  to  the  drying-out  of  the  already  mace- 
rated and  partially  disintegrated  mucous  membrane,  caused  by  the  con- 
stant mouth-breathing  of  the  patients,  who  at  this  stage  lie  in  a  semi- 
conscious condition  with  mouth  wide  open. 

These  fissures  occur  principally  on  the  posterior  wall,  which  faces  the 
interior  of  the  larynx,  and  develop  into  extensive  ulcers  that  spread 
usually  to  one  side,  and,  as  the  ulcerative  process  becomes  deeper,  attack 
the  cartilages  of  the  larynx,  particularly  the  arytenoid.  The  mucous 
membrane  covering  the  latter  swells  and  forms  a  smooth,  bluish-red, 
roundish  tumor  covered  by  a  whitish  exudate,  which  in  the  form  of  an 
edema  spreads  to  the  neighboring  portions  and  the  entire  entrance  to  the 
larynx,  and  may  seriously  endanger  the  patient's  life  by  asphyxia.  The 
patient  being  usually  in  a  very  low  condition,  quite  unconscious,  incapa- 
ble of  self-control,  and  so  weak  that  the  remaining  flicker  of  life  cannot 
resist  even  the  slightest  degree  of  dyspnea,  this  danger  is  very  great, 
and  it  is  of  great  importance  to  bear  it  constantly  in  mind.  Hence,  in 
any  severe  case  the  earliest  appearance  of  cyanosis  or  any  other  symptoms 
of  interference  with  respiration  must  be  carefully  looked  for,  and  trache- 
otomy be  performed  without  undue  delay. 


SYMPTOMATOLOGY.  545 

In  not  a  few  cases  perichondritis  leads  to  necrosis  of  the  cartilage, 
and  occasionally  even  to  complete  separation  of  the  cartilage  from  its 
attachments,  so  that  it  lies  free  in  the  small  pus-cavity,  and  if,  as  I 
myself  once  observed,  perforation  takes  place,  the  cartilage  may  be 
expelled  when  the  patient  coughs. 

If  death  is  avoided  in  such  cases  by  timely  interference,  the  jjcriod 
of  defervescence  is  usually  extraordinarily  prolonged.  As  a  rule,  tlie 
patients  are  voiceless  for  the  remainder  of  their  lives  ;  and  sometimes 
stenosis  of  the  larynx  remains,  which  requires  a  long  and  tedious  course 
of  treatment  or  forces  the  patient  to  wear  a  cannula  permanently. 

In  16 — that  is,  4  per  cent. — of  our  cases  treated  in  the  Moahit  lazaretto  in 
1879  there  occurred  severe  laryngeal  affections.  This  does  not  include  a  .still 
greater  number  of  patients  who  developed  hoarseness  and  complete  aphonia 
at  the  height  of  the  disease,  but  in  whom  the  voice  was  restored  after  they 
recovered.  In  4  cases  tracheotomy  became  necessary  on  account  of  peri- 
chondritis of  one  of  the  arytenoid  cartilages  and  resulting  edema  of  the 
larynx.  Three  of  these  recovered,  but  had  to  wear  the  cannula  so  long  as 
they  were  under  my  observation ;  in  the  fourth  case,  operative  interference 
came  too  late. 

Perichondritic  abscesses  are  undoubtedly  the  direct  cause  of  many 
severe  pulmonary  and  pleuritic  complications,  particularly  certain  forms 
of  lobular  and  lobar  pneumonia  ending  in  gangrene  or  gangrenous 
pleurisy.  They  are  produced  by  aspiration  of  septic  masses  from  the 
abscesses,  which,  as  we  have  seen,  tend  to  rupture  into  the  interior  of 
the  larynx  after  a  certain  time. 

I  do  not  mean  to  say  that  all  cases  of  gangrene  of  the  lungs  and 
empyema  are  referable  to  purulent  affections  of  the  larynx,  for  there  is 
no  doubt  that  putrid  inflammations  of  the  pulmonary  tissues  may  be 
produced  in  ways  other  than  by  aspiration.  I  do  maintain,  however, 
that  infection  from  the  larynx  plays  a  very  much  more  important  part 
than  has  hitherto  been  supposed  or  reported  in  the  literature. 

During  the  epidemic  of  1879  we  observed  6  cases  of  gangrenous  disease 
of  the  lungs  accompanying  perichondritic  abscess.  Five  of  these  occurred 
in  the  right  lower  lobe,  which,  owing  to  its  shape  and  the  course  of  its  prin- 
cipal bronchus,  appears  to  be  much  more  accessible  to  aspirated  material 
than  its  fellow  of  the  left  side. 

Five  of  these  cases  ended  fatally — the  total  number  of  deaths  was  93  ; 
the  sixth,  in  which  there  was  a  small  circumscribed  gangrenous  focus  in 
the  lower  lobe  of  the  right  lung,  finally  ended  in  recovery  after  a  prolonged 
illness,  and  after  the  laryngeal  affection  had  been  cured. 

Diseases  of  the  I/Ung  Parenchyma  and  the  Pleura. — 

Among   the    most    frequent    pulmonary   diseases    in    typhus    fever,   in 
addition  to  the  atelectasis  and  hypostatic  congestion  that  have  alreadv 


546  TYPHUS  FEVER. 

been  referred  to,  is  a  form  of  fibrinous  pneumonia  that  cannot  be  distin- 
guished microscopically  from  the  ordinary  forms.  Xo  bacteriologic 
examination  has  so  far  been  made. 

It  develops  in  the  second  week  of  the  disease,  rarely  earlier,  and,  as 
the  patients  at  this  time  are  usually  in  a  stuporous  or  comatose  condi- 
tion, there  are  ho  marked  symptoms.  Occasionally,  an  increase  in 
the  respiratory  rate  or  a  rise  of  temperature  points  to  its  occurrence. 
Rusty  sputum  or,  in  fact,  expectoration  of  any  kind,  is  often  absent. 
Only  frequent  and  careful  examinations  of  the  patient  will  therefore 
insure  the  detection  of  this  com])lioation.  I  am  inclined  to  doubt  that 
the  marbled  and  almost  whitish  appearance  of  the  infiltrated  portions  of 
the  lung,  pointed  out  by  Salomon,  are  due  to  any  peculiar  pathologic 
alteration.  They  are  more  naturally  explained  by  the  general  anemia 
that  is  usually  present. 

Fibrinous  pneuinouia  in  typhus  fever  varies,  as  regards  the  frequency 
of  its  occurrence,  according  to  time  and  place.  On  the  whole,  it  appears  to 
be  distinctly  more  frequent  than  in  typhoid  fever,  and  runs  a  decidedly 
more  severe  course.  In  1879  we  had  to  report  fibrinous  pneumonia  as  the 
immediate  cause  of  death  in  14  cases,  or  15  per  cent,  of  all  fatal  cases  ;  but  3 
cases  in  \Yhich  this  diagnosis  was  made  ended  in  recovery. 

Inflammation  of  the  pleura  is  also  distinctly  more  frequent  than  in 
typhoid  fever.  It  is  apt  to  follow  lobular  and  lobar  pneiunonin,  and 
especially  purulent  pneumonia,  and  leads  to  purulent  and  putrid  effu- 
sions, so  that  operations  for  empyema  are  quite  often  required. 

The  pleuritic  aifections,  like  pneumonia,  are  quite  likely  to  be  over- 
looked. The  patients  often  do  not  complain  of  pain  in  the  side,  and 
pleuritic  friction  is  frequently  absent,  partly,  no  doubt,  on  account  of 
the  peculiar  soft  consistence  of  the  fibrinous  exudate,  and  partly  also 
on  account  of  the  limited  respiratory  movements. 

Almost  all  authors  agree  in  mentioning  pulmonary  tuberculosis  or 
general  miliary  tuberculosis  as  an  occasional  complication  of  typhus 
fever.  It  may  make  its  appearance  during  the  height  of  the  disease,  or 
even  during  the  later  stages  of  convalescence. 

From  our  present  knowledge  of  the  disease,  it  is  certain  that  such 
cases  are  always  due  to  a  latent  tuberculosis  that  has  been  lighted  up 
again  by  the  typhus  fever. 

Among  the  patients  under  my  care  in  1878  and  1879  there  was  1  case 
of  general  miliary  tuberculosis,  4  cases  of  fulminating  (florid)  pulmonary 
jihthisis,  and  1  case  of  chronic  ulcerative  infiltration  of  the  lower  lobe  of 
the  left  lung,  following  immediately  on  an  acute  lobar  fibrinous  consoli- 
dation. 


SYMPTOMATOLOGY.  547 

ALTERATIONS   IN   THE   DIGESTIVE   TRACT. 

Digestive  disturbuuces  are  of  fur  less  importance  in  typhus  than  in 
typhoid  fever. 

The  absence  of  specific,  regularly  recurring  alterations  of  the  intes- 
tinal canal  in  typhus  fever  has  already  been  pointed  out  in  the  section 
on  Pathology.  Accordingly,  there  is  also  an  absence  of  pain  in  the 
region  of  the  small  intestine,  and  any  noteworthy  degree  of  tympanites 
is  rarely  observed.  I  believe  that  it  occurred  in  only  1  per  cent,  of  my 
cases. 

Pain,  localized  in  the  right  iliac  region,  with  gurgling,  never  occurs 
in  typhus  fever. 

As  there  is  no  constancy  in  the  anatomic  appearances  of  the  intes- 
tinal canal,  there  is  a  corresponding  absence  of  regularity  or  anything 
especially  characteristic  in  the  frequency  of  the  stools. 

As  a  rule,  there  is  constipation  during  the  first  week,  and  not  rarely 
during  the  entire  period  of  the  disease.  Later  on,  especially  at  the 
height  of  the  disease  and  during  defervescence,  diarrhea  occasionally 
occurs.  I  believe  that  alcoholics  are  more  disposed  to  diarrhea  than 
other  patients. 

There  is  nothing  characteristic  about  the  appearance  of  the  stools, 
even  when  they  are  semiliquid  or  quite  thin.  The  statements  of  certain 
physicians  that  the  stools  resemble  the  characteristic  pea-soup  stools  of 
typhoid  fever,  rest  simply  on  superficial  observations.  "When  the  diet 
consists  principally  of  milk  and  broths,  the  stools  may  be  yellowish- 
white  in  color,  but  they  are  never  watery  and  free  from  mucus,  there  is 
no  tendency  to  separate  in  layers,  and  the  coarse  granular  sediment  and 
sharp  ammoniacal  odor  characteristic  of  typhoid  fever  are  altogether 
wanting. 

As  hemorrhages  into  the  gastric  and  intestinal  mucous  membrane 
have  occasionally  been  observed  at  the  autopsies  of  very  severe  cases, 
there  is,  of  course,  a  possibility  of  blood  appearing  in  the  stool  (Baral- 
lier,  Tweedie,  Frerichs,  and  others).  Such  cases  must,  however,  be 
very  exceptional,  and  the  reports  should  be  received  with  great  caution. 
There  is  always  a  possibility  that  the  blood  is  simply  a  concomitant 
symptom  of  a  hemorrhagic  diathesis,  or  a  mere  local  hemorrhage  from 
the  rectum,  or  hemorrhoids,  etc.  The  statements  of  some  of  the  older 
authors  in  regard  to  the  frequent  occurrence  of  intestinal  hemorrhage 
probably  depend  on  an  error  of  diagnosis  between  typhus  and  typhoid 
fever,  since,  as  we  know,  the  tAvo  diseases  were  not  infrequently  con- 
fused, as,  for  instance,  in  England  and  Ireland. 


548  TYPHUS  FEVER. 

One  of  the  cases  observed  in  ^loabit  in  1879  well  illustrates  the  neces- 
sity of  great  care  in  judging  these  hemorrhages. 

A  young  man,  several  of  whose  relatives  had  been  treated  in  the  laza- 
retto for  typhus  fever,  and  who  was  admitted  with  typical  symptoms  of  a 
severe  attack  of  the  disease,  had  a  profuse  hemorrhage  on  the  ninth  day 
of  his  illness  that  evidently  came  from  some  of  the  higher  portions  of  the 
intestine.  At  the  autopsy,  the  source  of  the  hemorrhage  was  found  in  a 
duodenal  ulcer  that  was  evidently  of  long  standing. 

There  is  little  of  importance  to  say  regarding  other  portions  of  the 
intestinal  tract. 

During  the  first  day  the  tongue  is  thickly  covered  with  a  whitish 
or  yellowish-brown  exudate.  As  the  patient  becomes  more  and  more 
apathetic  and  his  mental  condition  more  clouded,  the  tongue  becomes 
leather}',  dry,  tremulous,  covered  with  crusts  and  marked  by  fissures,  or 
smooth  and  glazed  (Obermeicr).  The  gums  and  lips  are  also  dry  and 
covered  with  sordes.  This  dryness  cannot  be  avoided  altogether  even 
with  the  best  care  during  the  height  of  the  disease. 

]More  rarely  there  is  a  scorbutic  softening  of  the  gums  and  other 
portions  of  the  oral  mucous  membrane,  with  a  tendency  to  hemorrhages. 

The  soft  palate  and  the  tonsils  are  at  first  of  a  deep-red  color  and 
macerated ;  later  they  become  dirty  yellow,  dry,  and  covered  with 
strands  of  tenacious  mucus  and  dry  crusts. 

In  a  few  epidemics  and  in  rare  cases  diphtheric  affections  of  the 
pharyngeal  structures  occur,  followed  by  superficial  or  even  deep  ulcers. 
Personally,  I  have  seen  3  cases  of  this  kind ;  2  of  them  ended  fatally, 
and  the  third  recovered  after  a  much  protracted  convalescence. 

CHANGES   IN   THE   GENITO-URINARY   ORGANS. 

The  changes  in  the  kidneys  and  their  secretion,  so  far  as  is  known,^ 
is  practically  the  same  as  in  other  acute  infectious  diseases,  especially  in 
severe  cases  of  the  acute  exanthemata. 

From  the  very  earliest  days  of  the  disease  until  past  the  height  of 
the  febrile  period  the  urine  is  scant  in  quantity — that  for  twenty-four 
hours  rarely  exceeding  from  1000  to  1200  c.c. — is  high  in  specific 
gravity,  and  strongly  acid,  with  an  abundant  sediment  of  uric  acid  and 
urates. 

As  the  fever  subsides,  and  during  the  period  of  convalescence,  the 
urine  is  lighter  in  color,  clear,  and  sometimes  very  abundant. 

Griessinger,  who  also  quotes  Jenner  and  Finger  as  authorities, 
repeatedly  saw,  during  the  height  of  the  fever,  a  temporary  secretion 

'  The  most  careful  work  on  this  question  has  been  done  by  Pribram  and  Robi- 
schek,  "Wyss,  Rosenstein,  and  Lanceraux. 


SYMPTOM  A  TOL  0  G  Y.  549 

of  large  quantities  of  clear,  pale  urine.  I  myself  have  observed  this 
several  times,  especially  a  short  time  before  tlie  beginning  of  deferves- 
cence. This  phenomenon,  which  I  have  never  observed  in  typhoid 
fever,  is  difficult  to  explain. 

Durina:  the  heio-ht  of  the  disease  the  excretion  of  urea  is  often  not 
increased,  sometimes  it  is  even  diminished  (Kosenstein,  Lanceraux)  ; 
while  the  excretion  of  uric  acid  is  always  distinctly  increased. 

Lanceraux,  even  when  the  patients  were  taking  large  quantities  of  milk, 
never  obtained  more  than  fi-om  11.5  to  24  gm.  of  urea  in  twenty-four  hours. 

Rosenstein  found  that  the  secretion  of  urea  was  at  first  considerably 
increased;  during  the  subsequent  course  of  the  fever  it  fell  far  below  the 
physiologic  daily  amount,  and  during  convalescence  it  again  rose  gradually. 
His  findings  show  a  remarkable  agreement  with  those  obtained  by  Barallier 
as  early  as  1861. 

Others  among  the  older  authors  (Parkes,  Buchanan)  speak  of  a  continu- 
ous marked  increase  in  the  production  of  urea  during  the  height  of  the 
disease.  These  discrepancies  suggest  the  necessity  of  careful  investigations, 
during  future  epidemics,  with  the  improved  methods  that  are  now  at  our 
disposition. 

The  chlorids  regularly  undergo  marked  diminution,  and  sometimes 
reach  a  minimum  during  the  febrile  period.  From  the  beginning  of  the 
second  week  it  is  often  impossible  to  demonstrate  them. 

As  we  should  expect  from  the  frequency  of  cloudy  swelling  in  the 
kidney  during  the  height  of  the  disease,  as  shown  by  numerous  autop- 
sies, there  is  usually  a  moderate  febrile  albuminuria  in  the  febrile  stage 
in  severe  and  moderately  severe  cases.  The  albuminuria  occasionally 
makes  its  appearance  as  early  as  the  middle  of  the  first  week,  more  fre- 
quently toward  the  end  of  the  first  or  beginning  of  the  second  week, 
and  disappears  with  defervescence,  or  occasionally  a  few  days  before 
that  period.  Microscopic  examination  of  the  urine  in  such  cases  shows, 
in  addition  to  crystalline  sediments,  only  a  few  epithelial  elements  from 
the  kidney  and  pelvis,  and  hyaline  casts  in  moderate  numbers. 

Severer  grades  of  albuminuria,  lasting  into  the  period  of  conva- 
lescence and  accompanied  by  bloody  urine  and  numerous  renal  epithelial 
cells  and  epithelial  casts  m  addition  to  hyaline  casts,  indicate  parenchy- 
matous nephritis,  a  complication  of  unfavorable  prognostic  significance 
that  fortunately  is  rare.  In  a  few,  but  by  no  means  all,  cases  it  ends 
fatally  with  symptoms  of  uremia.  Five  cases  in  which  we  could  demon- 
strate parenchymatous  nephritis  at  the  autopsy  had  been  clinically  quite 
free  from  uremic  symptoms. 

In  young  individuals,  especially  in  children,  albuminuria  with  abun- 
dant admixture  of  blood  in  the  urine  has  been  observed  on  the  fourth 
or  fifth  day  of  the  disease  (Weiss),  even  before  the  appearance  of  the 


OuU  TYPHUS  FEVER. 

oru])tion.  The  prognosis  in  such  cases,  which,  as  a  rule,  are  complicated 
with  pneumonia,  is  quite  as  bad  as  in  similar  conditions  among  adults. 

If  the  patients  survive  .the  nephritis,  thcv,  as  a  rule,  make  a  com- 
plete recovery  after  a  variable  period  of  time  ;  recovery  is  undoubtedly 
much  more  frequent  than  in  nephritis  accompanying  angina  simplex, 
diphtheria,  and  scifrlet  fever. 

It  is  worth  noting  that  some  recent  observers,  A'ierordt  among  them, 
have  obtained  a  positive  diazo-reaction  with  a  fail-  degree  of  regularity 
in  their  analyses  of  typhus  urines,  which  is  a  point  of  similarity  between 
typhus  fever  and  typhoid  fever  and  a  number  of  the  acute  exanthemahi. 

Occasionally,  the  urine  also  gives  Gerhard's  ferric  chlorid  reaction. 
The  occurrence  of  sugar  iu  the  urine,  observed  in  several  cases  by 
Buchanan,  has  not,  so  far  as  I  know,  been  confirmed  by  any  other 
authority. 

Bladder  disturbances  of  any  severity  are  not  of  frequent  occur- 
rence ;  and,  although  we  repeatedly  found  hemorrhages  into  the  mucous 
membrane  at  the  autopsy,  the  condition  had  not  produced  any  symp- 
toms during  life. 

Retention  of  urine  is  very  rare  in  men,  but  quite  common  in  women, 
especially  during  the  febrile  stage.  While  we  had  to  use  the  catheter 
on  males  in  only  2  instances  in  the  epidemic  of  1879,  a  daily,  or  at 
least  an  occasional,  resort  to  the  catheter  was  necessary  in  almost  all 
the  female  cases. 

In  regard  to  changes  in  the  genital  organs  in  typhus  fever,  our 
knowledge  is  Yery  limited. 

The  Male  Genital  Organs. — Orchitis  appears  to  be  even  more 
rare  in  typhus  than  in  typhoid  fever.  I  saw  a  single  case  of  unilateral 
orchitis  in  a  young  man  shortly  before  the  crisis ;  it  lasted  ten  days, 
and  subsided  without  going  on  to  suppuration.  Most  of  the  authors 
do  not  even  mention  orchitis. 

The  F^emale  Genital  Organs. — On  the  other  hand,  the  dis- 
ease appears  to  have  a  marked  effect  on  the  female  genital  organs, 
manifesting  itself  in  a  variety  of  ways.  The  effect  on  menstruation 
is  similar  to  that  observ^ed  in  other  acute  infectious  diseases. 

The  onset  of  the  disease  is  quite  frequently  accompanied  by  prema- 
ture menstrual  flow.  The  flow  is  often  more  profuse  than  in  health, 
and  occasionally  the  hemorrhage  is  so  severe  as  to  have  a  marked  weak- 
ening effect  that  shows  itself  in  the  subsequent  course  of  the  disease. 
If  the  disease  occurs  shortly  after  the  last  menstrual  period,  menstrua- 
tion is  almost  always  suspended  during  the  entire  duration  of  the  attack. 
In  mild  cases  the  menstrual  flow  reappears  soon  after  the  period  of 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS  OF  DISEASE.   551 

defervescence,  and  may  even  be  increased  in  amount.  After  severe 
cases,  on  the  other  hand,  its  appearance  may  be  delayed  for  some  time. 

Pregnant  women  do  not  appear  to  liave  any  special  predispo- 
sition to,  nor  docs  pregnancy  afford  any  protection  against,  the  disease. 

The  effect  of  the  malady  on  pregnancy  has  been  overestimated  by 
many  authors.  Typhus,  like  typhoid,  fever  is  not  by  any  means  so 
dangerous  to  a  pregnant  woman  as  is  variola.  A  large  percentage,  if 
not  half,  of  all  pregnant  women  have  the  disease  without  suffering 
abortion  or  premature  labor.  This  is  true  particularly  in  cases  in  which 
the  disease  makes  its  appearance  during  the  later  months  of  pregnancy, 
but  even  during  the  earlier  months  abortion  is  by  no  means  a  constant 
occurrence. 

The  English  physicians,  who  have  probably  enjoyed  the  greatest 
experience  in  this  respect,  believe  that  typhus  fever  has  a  slighter  effect 
on  the  course  of  pregnancy  than  has  any  other  acute  infectious  disease. 
Wardell  states  that  he  has  never  seen  an  mterruption  of  pregnancy 
during  the  course  of  typhus  fever,  although  it  must  be  admitted  that 
his  statement  would  carry  greater  weight  if  it  were  based  on  a  larger 
number  of  cases. 

Even  when  pregnancy  is  interrupted  by  the  disease,  the  accident  is 
not  always  followed  by  grave  consequences.  The  greatest  danger  to 
the  patient  is  that  of  severe  hemorrhage.  After  studying  a  number  of 
these  cases  one  gets  the  impression,  however,  that  the  metrorrhagia  is  not 
a  result  of  the  expulsion  of  the  fetus,  but  rather  that  the  hemorrhage 
occurs  because  the  disease  has  assumed  a  "  hemorrhagic  character." 

VARIATIONS  IN  THE  COURSE  AND  MANIFESTATIONS 
OF  THE  DISEASE. 

The  end  of  the  febrile  period  in  almost  every  case  marks  the  end  of 
the  disease. 

RELAPSES  AND  RECURRENCES. 
Relapses  and  recurrences,  so  common  in  typhoid,  are  of  the  greatest 
rarity  in  typhus,  another  among  the  many  points  of  resemblance  between 
this  disease  and  the  acute  exanthemata.  Although  some  authors,  among 
them  Baralher,  claim  to  have  observed  relapses  frequently,  they  have 
failed  to  produce  any  positive  proof  for  their  statements,  for  it  is  abso- 
lutely necessary  to  exclude  with  certainty  other  complications  or  sequels 
as  causes  of  the  renewed  fever,  and  to  show  that  the  rise  in  temperature 
was  immediately  followed  by  a  second  appearance  of  the  characteristic 
rash. 


552 


TYPHUS  FEVER. 


Murchison  himself  never  saw  an  un(lou))ted  ease  of  relapse  or  recurrence, 
and  Griessinger  denies  its  recurrence  alisolutely.     Jenuer,  Stewart,  and,  more 


recently,  Thoinot,  each  saw  1  case,  and  even  Buchanan  (see  Murchison) 
could  not  find  more  than  1  case  of  undoubted  relapse  to  record  among  5000 
cases  in  the    Loudon    Fever  Hospital.     I    myself  have  2  observations  to 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS   OF  DISEASE.    -053 

report  that,  I  believe,  are  undoubted  cases  of  relapse,  but  I  will  also  a<]d 
that  I  believe  the  eases  to  be  anomalous,  vvhicli  is  proved   by  the  fact  tliat 


both  of  them  occurred  in  1878  among  a  very  small  number  of  patients, 
while  in  1879  we  failed  to  observe  anything  in  the  least  resembling  a  relapse 
or  a  recurrence. 


554  TYPHUS  FEVER. 

The  first  case  was  that  of  a  laborer,  twenty -six  years  of  age,  who,  after  a 
severe,  uncomplicated  case  of  typhus  fever  terminating  by  lysis,  entered 
upon  his  convalescence  on  the  seventeenth  day.  After  this  period  he  was 
free  from  fever,  his  temperature  being  usually  subnormal.  Eleven  days 
later,  the  patient  being  still  in  bed  because  he  was  very  weak  and  emaciated, 
he  had  another  chill  and  the  temperature  rose  rapidly.  The  spleen,  which  had 
not  been  en largeil  before,  was  distinctly  })alpable  and  sensitive  to  pressure. 
On  the  third  day  of  the  disease  there  was  a  distinct,  though  scanty,  erup 
tiou  of  rose-sjjots  on  the  abdomen  and  chest,  with  a  few  spots  on  the  extremi- 
ties, including  the  dorsal  surfaces  of  the  feet,  the  rose-sjjots  later  in  part 
undergoing  a  petechial  transformation.  On  the  fifth  day  the  temperature 
fell  by  crisis  (Fig.  62)  and  the  patient  began  to  mend,  and  this  time  his 
recovery,  although  protracted,  was  not  again  interru})ted. 

In  the  second  case  the  most  marked  feature  was  the  short  duration  of 
the  afebrile  period  between  the  end  of  the  primary  attack  and  the  beginning 
of  the  relapse,  so  that  the  case  rather  resembles  what  is  usually  described  as 
a  recurrence.  The  patient  was  a  carpenter,  twenty -five  years  of  age.  After 
an  attack  of  typhus  marked  by  extremely  high  temperature,  the  fever  fell 
by  lysis  on  the  eleventh  day  (Fig.  63).  The  rash  had  disappeared  except 
for  a  few  dirty-brown  and  yellowish-green  spots.  Except  for  a  marked 
catarrhal  aftection  of  the  larynx  no  organic  disease  of  any  consequence  had 
developed  ;  albumin  had  never  been  found  in  the  urine.  During  the  night 
between  the  second  and  the  third  day  after  the  subsidence  of  fever  the 
patient  had  a  chill  and  the  temperature  again  began  to  rise,  reaching  39°  C. 
on  the  evening  of  that  day.  The  temperature  continued  moderately  high 
for  the  next  few  days,  and  then  gradually  began  to  fall  by  distinct  lysis,  the 
period  of  defervescence  being  completed  by  the  ninth  day.  On  the  very 
first  day  of  the  second  attack  of  fever  albumin  and  blood,  with  hyaline  and 
epithelial  casts  and  casts  covered  with  red  blood-cells,  made  their  appearance 
in  the  urine,  and  on  the  third  day  a  very  characteristic  and  moderately 
abundant  eruption  of  rose-spots  made  its  appearance.  Splenic  enlargement 
was  not  observed.  After  this  the  case  ran  an  ordinary  course.  The  symp- 
toms of  nephritis  disappeared  completely  after  four  and  one-half  weeks. 

VARIATIONS  IN  THE  COURSE. 

The  course  of  typhus  fever  Ls  subject  to  very  wide  variations,  which 
at  different  times  and  on  the  strength  of  observations  obtained  in  differ- 
ent epidemics  have  received  a  great  variety  of  different  names. 

Older  Nomenclature. — Thus,  it  was  formerly  the  custom  to  apply 
various  names  to  the  disease,  depending  on  the  prominence  of  symptoms 
referable  to  definite  groups  of  organs  or  to  single  organs. 

The  term  typhus  neri-osus  or  typhus  ataxicus  was  applied  to  cases 
with  unusually  severe  nen^ous  manifestations,  such  as  delirium,  coma, 
subsultus  tendinum,  and  carphology. 

When  loss  of  strength  with  cardiac  weakness  and  a  tendency  to 
collapse  made  its  appearance  early,  the  case  was  called  typhus  ataxo- 
adynamicus.  Typhus  dysentericus  was  diagnosed  when  diarrhea  or  true 
dysenteric   symptoms    formed    a    prominent    feature,    while    the    older 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS  OF  DISEASE.   555 

English  and  Irish  physicians  particularly  were  likely  to  speak  of 
typhus  catarrhalis  when  the  mucous  membranes  of  tlie  air-passages 
early  became  involved  and  presented  the   most  conspicuous  symptoms. 

These  names,  to  which  a  large  number  that  arose  in  a  similar  manner 
might  be  added,  have  little  more  than  a  historic  interest  at  the  f)resent 
day.  The  appearances  and  manifestations  of  the  disease  are  capable  of 
an  infinite  number  of  combinations,  and  the  number  of  clinical  ])ictures 
is  so  varied  that  it  can  be  neither  justifiable  nor  useful  to  dignify  indi- 
vidual forms  by  special  names. 

On  the  other  hand,  it  is  of  much  practical  utility,  not  to  say  of 
absolute  necessity,  for  a  proper  understanding  of  the  disease  to  form  a 
careful  estimate  of  the  diiferences  in  severity  and  duration,  and  use  a 
nomenclature  based  on  these  differences. 

We  will  first  consider  in  this  connection  cases  of  mild  degree,  cases 
of  short  duration,  and  abortive  cases,  which  in  typhus  fever,  as  in  all 
acute  infectious  diseases,  play  a  very  important  rdle. 

The  manifestations  and  the  course  of  these  forms  are  subject  to 
remarkable  variations,  and  the  conditions  on  which  they  depend  are 
even  yet  practically  unknown.  The  frequency  of  their  occurrence  varies 
with  the  time  and  variety  of  the  epidemic,  and  also  may  vary  during 
different  periods  of  the  same  epidemic.  As  the  epidemic  spends  its 
force,  a  remarkable  increase  in  the  number  of  milder  cases  is  often 
observed. 

I  think  we  are  justified,  in  studying  the  reasons  for  this  phenomenon, 
to  assume  a  gradual  decrease  in  the  strength  of  the  morbific  agent  as 
the  epidemic  progresses ;  or  it  may  be  assumed  that  after  most  of  the 
individuals  specially  predisposed  to  the  disease  have  been  attacked, 
those  who  are  less  disposed  to  it  also  become  affected.  We  cannot  hope 
to  gain  a  true  understanding  of  these  conditions  until  we  learn  more  of 
the  nature  of  the  typhus  fever  poison,  and  until  such  general  questions 
as  predisposition  and  immunity  have  been  further  elucidated. 

If  we  examine  cases  of  short  duration  and  cases  of  mild  degree 
more  carefully,  we  find  that  a  short  attack  is  by  no  means  necessarily 
characterized  by  a  mild  course.  A  case  may  be  mild  from  beginnmg  to 
end,  without  being  at  all  short  in  duration ;  and,  conversely,  cases  of 
short,  or  even  very  short,  duration  not  infrequently  present  a  grave 
clinical  picture,  not  only  during  the  active  course  of  the  disease,  but 
even  until  the  beginning  of  defervescence. 

Cases  of  Mild  Degree,  Well-marked  Cases,  and  Cases 
of  Short  Duration. — As  compared  with  the  frequency  of  mild  forms 
of  typhoid  fever  with  relatively  low  temperatures  known  as  "  gastric 


556 


TYPHUS  FEVER. 


fever "  or  "  mucous  fever,"  analogous  cases  of  typhus  fever  are 
distinctly  less  common.  l-]ven  ;<ueh  cases  a^j  end  rapidly  in  recovery 
witliout  anv  unusual  conipliciition  or  pernianent  injury  to  tlic  health  of 
the  individual,  sometimes^  ut  least,  run  their  course  \vith  high  fever  and 

correspondingly  severe  dis- 
turbances of  the  general 
condition.  In  any  epi- 
demic, however,  cases  will 
be  observed  in  which  the 
disease  runs  its  course  in 
tlie  usual  time — from  four- 
teen to  seventeen  days,  or 
even  longer — without  once 
manifesting  an  unusually 
high  temperature. 

These  mild  cases  gener- 
ally do  not  begin  with  a 
distinct  chill.  After  a 
period  during  which  the 
patient  complains  of  chilly 
feelings,  the  temperature 
rises  gradually,  by  succes- 
sive steps,  so  that  it  may 
not  reach  its  ultimate 
height  before  the  fourth 
day  of  the  disease.  Ac- 
cordingly, the  initial  symp- 
toms— headache,  backache, 
vomiting,  etc.  —  are  also 
less  severe,  and  in  many 
patients  the  mind  remains 
clear  even  in  the  evening 
and  during  the  night.  The 
subsequent  course  of  the 
fever  is  often  irregular, 
with  marked  remissions 
and  intermissions  (Fig.  04), 
and  the  period  of  defervescence  is  often  protracted.  The  pulse,  particu- 
larly in  men,  is  much  less  frequent  than  in  the  severe  cases,  and  in  women 
it  usually  remains  of  good  volume  and  tension  throughout. 

I  have  an  impression  that  splenic  enlargement  is  less  frequent  in  cases 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS  OF  DISEASE.   557 

of  this  kind,  and  that  the  rasli  also  is,   as  a  rule,   loss  well   marked. 
In  a  number  of  these  cases  catarrhal  laryngitis  and  tracheobronchitis 

Day  of  the  disease. 


Fig.  65. — Strolling  actor,  ag-ed  forty-seyen.    Short  and  mild  attack  of  typhus  fever. 

were  both  early  and  marked  features,  and  formed  the  most  conspicuous 
characteristics  of  the  clinical  picture. 

In  addition  to  these  cases  of  "  catarrhal  typhus  "  I  had  occasion  to 
observe  2  cases,  characterized  by  a  relatively  low  but  protracted  fever, 
lasting  in  1   case  as  long  as  twenty-two  days,  in  which  symptoms  of 


r^ 

Day  of  the  d 
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Fig.  66.— BaktT,  aged  twenty-one.    Abortive  attack  of  typhus,  ending  by  crisis. 

hemorrhagic  nephritis  were  at  first  very  conspicuous,  and  vanished  com- 
pletely after  the  end  of  defervescence.     In  the  case  in  which  the  fever 


558  TYPHUS  FEVER. 

lasted  twenty-two  days  the  rash  was  so  scauty  and  lasted  so  short  a  time 
that  the  diagnosis  might  have  remained  doubtful  if  the  examination  had 
been  at  all  superficial. 

A\'e  come  next  to  the  cases  characterized  by  siiort  duration  and  a 
mild  course.  The  morbid  phenomena  in  many  of  these  cases  are  even 
milder  than  in  the  foregoing  group.  The  splenic  enlargement  and  the 
eruption  are  only  very  sparingly  devel()i)0(l,  and  the  disease  ends  within 
frum  live  to  eight  days.  This  variety  is  illustrated  m  Fig,  Qb  (comjjare 
also  Fig.  66). 

These  are  the  cases  in  which  the  characteristic  clinicid  picture  is  often 
so  disguised  as  to  be  quite  unrecognizable.  If  they  are  the  first  ones 
during  an  epidemic,  the  diagnosis  is  practically  impossible,  and  even 
during  the  height,  or  toward  the  end  of  the  epidemic,  the  diagnosis  will 
depend  largely  on  the  history  and  the  determination  of  frequent  or  inti- 
mate relations  with  undoubted  cases  of  ty})hus  fever.  I  cannot  agree 
with  Griessinger  and  other  authors  who  maintain  that  the  rash,  or  at 
least  the  characteristic  roseolous  eruption,  is  constantly  absent  in  these 
cases,  which,  by  the  older  authors,  were  usually  designated  febricula. 
I  have  seen  patients  of  this  kind  exhibit  a  well-marked  and  charac- 
teristic eruption  which  lasted  even  longer  than  the  febrile  period  when 
the  latter  was  very  short. 

Abortive  Cases. — It  will  be  well,  for  practical  reasons,  to  make 
a  distinction  between  the  cases  of  "febris  exanthematica  levin  et  levissima  " 
just  described  and  those  in  which,  after  a  severe  onset  and  clmical 
course,  defervescence  makes  its  appearance  unexpectedly  early.  The 
term  "  abortive  typhus  "  may  with  propriety  be  applied  to  such  cases. 

In  the  cases  of  this  class  it  happens  more  frequently  than  in  those 
of  "  febris  exanthematica  levissima,"  although  by  no  means  constantly, 
that  the  highest  temperature — after  a  violent  initial  chill — is  reached 
within  from  trsventy-four  to  thirty-six  hours  or  even  earlier.  After  this 
time  the  temperature  usually  persists  for  several  days  at  its  maximum, 
in  the  form  of  a  continued  fever  or  continued  remittent  fever ;  less  fre- 
quently it  is  quite  irregular.  The  temperature,  which  may  be  extremely 
high,  then  falls  by  distinct  crisis  (Fig.  66)  lasting  but  a  few  hours,  and 
remains  normal. 

The  condition  of  the  patient  in  these  forms  is  often  extremely  alarm- 
ing for  several  days  or  even  until  just  before  the  beginning  of  deferves- 
cence ;  after  initial  phenomena  of  great  violence  the  patients  present 
marked  hebetude,  profound  prostration,  and  even  furious  delirium. 
The  condition  of  the  spleen  varies  greatly.  In  some  cases  I  have  seen 
a   marked   enlargement ;  in  others  the  organ  was  not   swollen  at  all. 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS  OF  DISEASE.   559 

The  rose-spots  in  abortive  forms  are,  as  a  rule,  few  in  number  and  last 
but  a  short  time,  although  sometimes  a  number  of  them  undergo 
petechial  transformation  or  petechise  may  develop  independently  among 
the  rose-spots.  The  eruption  of  large  macules  that  has  been  referred  to 
appears  to  be  more  common  in  abortive  cases  than  in  well-marked 
forms  of  the  disease ;  and  another  point  that  seems  to  me  worth  noting 
is  the  frequent  appearance  of  herpes  facialis  during  the  crisis. 

Grave  pulmonary  complications,  especially  pneumonia,  are  rare  in 
abortive  typhus  feVer,  although  sometimes  laryngitis  and  bronchitis,  as 
occasionally  occurs  in  cases  of  the  "  febris  exanthematica  levissima," 
form  a  prominent  feature  of  the  disease. 

In  a  few  cases  I  observed  an  unusually  slow  pulse  of  good  volume 


Day  of  the  disease. 

-p- 

T          a               3               4 

5                   6                    7 

44 

^t'^ 

*     ^    *   a               f 

^ i_2w!-w-a 

\-- 

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^t 

J-W 

39                                                               * 

I 

t 

A 

ISO 

3B 

■ 

1 

1 

, 

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Lt      R       i 

too 

L.3' i,,_,liSs „__ 

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^-?'»^--?-!;-- 

^  2~^ZZ^   I   Z*^ 

^      xd        Z.U 

1                                                   •, 

~%  ,.        ..i  .,- 

v"        ^ 

60 

30 

^_ 

Fig.   67.— Tailor,  aged  nineteen.    Abortive  course.    Slow  pulse  even  during  the  febrile  period. 

and  tension,  sometimes  not  exceeding  from  80  to  100  in  the  evening. 
This  phenomenon  in  itself  is  a  good  prognostic  sign,  and  justifies  the 
hope  that  the  course  of  the  disease  may  be  abortive  (Figs.  66  and  67). 

The  condition  of  the  kidneys  in  the  abortive  forms  is  usually  good. 
Slight  degrees  of  albuminuria  may  occur  :  marked  excretion  of  albumin 
with  blood  I  saw  in  only  1  case,  and  that  was  of  rather  long  duration,  so 
that  it  could  hardly  be  called  a  distinctly  abortive  case.  I  give  the 
temperature-chart  of  this  case  in  Fig.  68,  as  it  shows  not  only  the  course 
of  the  temperature,  but  also  the  occurrence  and  significance  of  a  rela- 
tively slow  pulse. 

These  cases,  it  need  hardly  be  said,  form  the  transition  between 
abortive  cases  and  those  of  moderate  severity  ending  in  recovery  in 
which  the  duration  is  not  abridged. 


560 


TYPHUS  FEVER. 


So  far  we  liave  discussed  cases  in  which,  as  \\c  have  seen,  a  diagnosis 
could  be  made  with  certainty,  or  at  least  with  a  fair  degree  of  probability, 
especially  if  they  were  under  observation  for  a  suiiicicntly  long  time. 
In  every  epidemic,  however,  especially  when   it  is  at  its  height   and 


toward  the  end,  cases  occur  that  cannot  be  diagnosed  with  certidnty  and 
in  which  the  interpretation  will  be  greatly  dependent  on  the  point  of 
view  of  the  observer.  In  these  cases  the  fever  lasts  but  a  short  time 
and  examination  fails  to  disclose  any  positive  signs  of  typhus,  such  as 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS  OF  DISEASE.   561 

the  characteristic  rash,  although,  at  the  same  time,  other  diseases  can  be 
positively  excluded,  and  the  history  shows  that  the  individuals  have  had 
close  relations  with  ty})hus  fever  patients. 

Some  of  these  cases  might  with  perfect  justice  be  called  "febris  exan- 
thematica  sine  exanthemate/'  in  imitation  of  analogous  cases  that  occur 
in  variola  and  scarlet  fever. 

This  form  is  mentioned  in  the  writings  of  other  authors,  especially 
the  more  recent  ones,  among  whom  I  may  name  Rosenstein  and  I*saunyn  ; 
the  former  claims  to  have  observed  it  quite  frequently. 

Finally,  we  have  a  group  of  most  perplexing  cases,  baffling  all 
attempts  at  diagnosis.  Individuals  who  have  for  a  long  time  been 
exposed  to  the  influences  of  the  typhus  fever  poison  develop  a  condition 
of  general  depression,  loss  of  appetite,  insomnia,  pain  in  the  head  and 
limbs,  ringing  in  the  ears,  bleeding  at  the  nose,  and  irregular  febrile 
disturbances  lasting  for  days  or  even  weeks,  without  ever  exhibiting 
any  pronounced  symptoms  of  the  disease.  Physicians,  ward  attendants, 
and  other  persons  whose  duties  bring  them  in  contact  with  typhus  fever 
patients  are  particularly  prone  to  develop  this  condition,  and  it  is  a 
noteworthy  fact  that  they  usually  recover  very  quickly  as  soon  as  they 
are  removed  from  their  unfavorable  surroundings.  Jaquot  has  described 
this  condition,  which  he  calls  "  typhisation  ci  petite  dose,'^  a  term  that 
sufficiently  describes  his  interpretation. 

Ambulatory  Cases. — In  this  connection  the  question  comes  up 
whether  walking  cases  occur  in  typhus,  as  in  typhoid,  fever.  Some  of 
my  own  observations,  I  believe,  point  to  the  occurrence  of  such  cases, 
if  not  with  certainty,  at  least  with  a  fair  degree  of  probability,  and 
among  other  authors  I  may  quote  Becher  and  Passauer,'  in  whose 
writings  similar  statements  may  be  found. 

The  frequency  of  mild  and  very  mild  cases  also  appears  to  vary  with 
the  period  and  the  individual  epidemic.  The  fact  that  some  authors  do 
not  mention  them  does  not  indicate  that  they  did  not  occur,  but  rather 
that  the  clinical  material  Avas  observed  under  peculiar  circumstances. 

It  is  worth  noting  that  children  appear  to  be  more  frequently 
attacked  by  this  form  of  the  disease  than  do  adults  (Griessinger,  "Wyss)^ 
and  that  the  milder  forms  often  become  more  prevalent  among  adults 
toward  the  end  of  the  epidemic,  particularly  among  individuals  who, 
owing  to  favorable  surroundings  and  good  physical  condition,  may  be 
assumed  to  possess  a  greater  resistance  to  the  poison. 

It  is  difficult  at  this  time  to  give  any  figures  in  regard  to  the  frequency 
of  cases  of  short  duration.     Among  347  cases  in  Moabit  analyzed  by  my 

1  Berlin,  klin.  Wochenschr.,  1868. 
36 


562  TYPHUS  FEVER. 

assistant,  Saloinou,  24  were  free  from  fever  on  from  the  seventh  to  the  ninth 
day.  It  will  be  seen,  therefore,  that  we  failed  to  get  the  mildest  and  shortest 
oases,  for  the  simple  reason  that  they  rarely  enter  the  hospital,  and  are  seen 
practically  only  in  private  practice.  It  is  rather  interesting  that  Murchison, 
who  has  given  so  careful  a  descrij)tion  of  the  disease,  fails  to  say  anything 
about  this  class  of  cases.  His  statistics  in  regard  to  the  duration  of  the 
disease  do  not  include  any  cases  of  less  than  one  week's  duration.  Among 
53  patients,  he  had  3  in  whom  the  disease  ended  on  the  eighth  or  ninth  day. 

RELATIONS  TO,    AND    COEXISTENCE  WITH,  OTHER  DISEASES. 

Acute  Exanthemata. — The  most  interesting  relation  is  that 
which  exists  between  typhus  fexcr  and  the  acute  exanthemata,  to  A\'liich 
it  is  so  nearly  related.  It  may  be  stated  that  typhus  fever  probably 
does  not  occur  simultaneously  with  the  acute  exanthemata,  although 
isolated  instances  of  such  occurrence  are  mentioned  in  the  literature. 
The  reports  arc  not  convincing,  however,  and  the  foregoing  statement 
must  hold  good  until  more  positive  cases  are  reported. 

Murchison,  who  does  not  himself  appear  to  have  met  with  the  com- 
plication under  discussion,  gives  Barallier  and  Buchanan  as  his  authori- 
ties for  the  simultaneous  occurrence  of  small-pox  and  typhus  fever. 

Baralliei"'s  statements  cannot  well  be  investigated,  and  Buchanan's 
case,  the  history  of  which  Murchison  quotes  in  full,  unquestionably 
admits  of  more  than  one  interpretation. 

In  regard  to  the  coexistence  of  typhus  and  scarlet  fever  we  also 
lack  reliable  information,  and  the  statements  in  regard  to  the  compli- 
cation with  measles  are  more  than  uncertain,  because,  as  we  have  seen, 
both  diseases  during  their  initial  stage  present  the  symptoms  of  con- 
junctival and  bronchial  catarrh,  and  because  the  morbilliform  rash  of 
typhus  fever  is  sometimes  indistinguishable  from  a  fugacious  eruption 
of  measles. 

We  must,  however,  clearly  distinguish  between  actual  coexistence 
and  a  rapid  or  even  immediate  succession  of  typhus  fever  and  the  acute 
exanthemata.  That  infection  with  one  of  the  acute  exanthemata  may 
occur  during  convalescence  or  even  toward  the  end  of  defervescence  in 
typhus  ;  and,  conversely,  that  individuals  recovering  from  scarlatina, 
measles,  or  variola,  may,  owing  to  some  unfortunate  accident,  imme- 
diately contract  typhus  fever  cannot  be  denied. 

I  may  mention  the  case  of  a  young  man,  eighteen  years  of  age,  in  whom 
a  well-marked  rash,  which  for  the  most  part  immediately  became  petechial, 
developed  while  the  skin  was  still  undergoing  the  typical  lamellar  desqua- 
mation of  scarlet  fever.  He  had  a  severe  attack  of  typhus  fever  which 
ended  in  recovery.  Murchison,  out  of  a  total  of  7  cases  of  typhus  follow- 
ing immediately  upon  scarlet  fever,  twice  saw  the  disease  develop  during 
the  period  of  desquamation. 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS  OF  JJJSFASE.   563 

Other  Acute  Infectious  Diseases. — A  number  of  tlieso  are 
capable  of  being  combined  with  typhus  fever  during  the  height  of  the 
febrile  stage  or  toward  the  end,  or  during  the  beginning  of  convales- 
cence. 

This  applies  particularly  to  pyemia  and  septic  processes 
caused  by  streptococci  and  staphylococci,  especially  erysipelas. 

The  occurrence  of  fibrinous  pneumonia,  due  to  the  action  of 
the  Frankel-Weichselbaum  bacillus,  during  the  febrile  period  of  typhus 
fever  has  already  been  referred  to  as  a  distinctly  frequent  and  very 
grave  complication. 

In  this  connection  acute  tuberculosis,  especially  acute  miliary 
tuberculosis,  is  spoken  of  by  all  authorities.  It  may  develop  in  any 
stage  of  typhus  fever,  but  occurs  most  frequently  toward  the  end  of  the 
febrile  period  or  during  convalescence.  I  have  observed  this  compli- 
cation 5  times.  One  case,  occurring  in  a  young  woman  twenty-three 
years  of  age,  presented  a  typical  picture  of  acute  basilar  meningitis,  the 
first  symptoms  appearing  toward  the  end  of  the  second  week  of  an 
attack  of  typhus  fever  with  moderately  severe  onset. 

The  relation  between  typhus  fever  and  relapsing"  fever  is  both 
interesting  and  important  from  a  prognostic  standpoint.  That  the  dis- 
eases may  coexist  is  beyond  all  doubt.  It  is  probable  that  the  stage 
of  incubation  of  typhus  fever  may  begin  during  the  continuance  of  an 
existing  relapsing  fever ;  whereas,  conversely,  the  spirillum  of  relapsing 
fever  probably  does  not  become  pathogenic  in  the  body  of  a  typhus 
fever  patient,  or  at  least  such  an  occurrence  is  extremely  rare. 

I  have  already  given  a  brief  account,  with  the  temperature-curve  (Fig. 
57),  of  a  case,  observed  in  Moabit  in  1879,  of  typhus  immediately  follow- 
ing an  attack  of  relapsing  fever.  Similar  complications  of  typhus  and 
relapsing  fever  had  been  repeatedly  observed  before  that  time.  Such  cases 
are  probably  not  rare  when  the  two  diseases  are  epidemic  at  the  same  time. 
The  combination  was  not  unknown  to  Griessinger  ;  and  Hermann  ^  mentions 
not  only  the  onset  of  typhus  one  to  three  weeks  after  an  attack  of  relapsing 
fever,  but  also  cases  in  which  typhus  fever  appeared  to  follow  directly  upon 
the  latter  disease.  Spitz  ^  reports  that  in  the  Breslau  typhus  epidemic  of 
1879  several  relapsing  fever  patients,  after  they  had  been  in  the  hospital 
from  three  to  five  weeks  without  coming  in  contact  with  typhus  fever  cases, 
were  attacked  by  the  disease.  One  of  these  cases  closely  resembles  ours  in 
the  absence  of  any  interval  between  the  end  of  the  relapsing  fever  attack 
and  the  beginning  of  typhus.  Seeliger  '  also  reports  4  instances  of  typhus 
infection  during  an  attack  of  relapsing  fever,  and  19  cases  in  which  typhus 
declared  itself  a  short  time  after  the  patient  had  recovered  from  relapsing 
fever. 

^  Petersb.  med.   Wochenschr.,  1876.  ^  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  xxvi 

^  Berlin,  klin.   Wochenschr..,  1888,  N"os.  51,  52. 


564  TYPHUS  FEVER. 

That  typhus  and  typhoid  fever  cau  exist  together  seems  to  me 
very  uiiprobable,  or  at  least  open  to  question.  Unfortunately,  many  of 
the  statements  on  this  subject  are  of  little  value.  Some  of  them  date 
from  a  time  when  the  two  diseases  were  not  carefully  distinguished, 
while  many  others  antedate  the  discovery  and  study  of  the  Eberth 
bacillus. 

I  am  equally  dismclined  to  accept  the  numerous  statements  in  regard 
to  the  coexistence  of  typhus  fever  and  diphtheria.  Diphtheric 
changes,  in  the  simple  anatomic  sense,  are,  of  course,  known  to  every 
experienced  observer,  but  it  remains  for  bacteriologic  investigations  in 
future  epidemics  to  show  whether  these  changes  ever  depend  on  the 
Loffler  bacillus,  and  can  therefore  be  interpreted  as  diphtheric  in  the 
etiologic  sense. 

The  coexistence  of  dysentery  and  typhus  fever  I  consider  very 
probable.  I  myself  saw  2  cases  in  which  dysenteric  manifestations, 
with  raucous  and  bloody  stools  and  separation  of  the  intestinal  mucous 
membrane  in  shreds,  formed  prominent  symptoms  of  the  disease. 

Murchison  regards  dysentery  as  a  rare  complication,  occurring  with 
any  degree  of  frequency  only  in  certain  epidemics.  Thus,  during  the 
Crimean  war  the  two  diseases  existed  side  by  side,  and  among  the 
French  soldiers,  who  lived  amid  unfavorable  hygienic  conditions,  cases 
were  observed  in  which  the  same  individual  was  attacked  by  both 
diseases. 

Acute  articular  rheumatism  and  typhus  fever  may  be  com- 
bined in  the  sense  that  the  latter  can  be  acquired  during  the  existence 
of  a  polyarthritis.  An  instructive  case  in  this  respect  is  that  of  a  man, 
thirty  years  of  age,  in  the  Charity  Hospital,  who  became  infected  during 
the  febrile  stage  of  an  acute  articular  rheumatism,  and  was  admitted  to 
the  lazaretto  in  Moabit  with  a  severe  case  of  typhus,  complicated  by 
hemorrhagic  nephritis. 

The  Relations  between  Typhus  and  Chronic  Affections. 
— The  relations  between  typhus  and  other  diseases,  especially  chronic 
conditions,  have  been  repeatedly  referred  to. 

I  do  not  believe  that  any  disease  affords  a  protection  against  typhus 
fever.  On  the  contrary,  not  a  few  chronic  conditions  characterized  by 
malnutrition  and  loss  of  strength  seem  to  heighten  the  predisposition  of 
the  individual. 

Among  such  conditions  chronic  alcoholism  is  especially  to  be 
mentioned.  Not  only  are  a  great  number  of  alcoholics  found  among 
the  classes  usually  attacked  by  the  disease,  but  it  is  a  fact  that  such 
individuals  are  actually  more  prone  to  contract  it. 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS  OF  DISEASE.   565 

The  course  of  the  disease  assumes  also  a  special  character  in  alcoholic 
subjects ;  it  is  distinctly  more  severe  and  is  more  likely  to  terminate 
fatally  than  in  persons  free  from  the  vice.  There  is  no  doubt  that  it 
largely  explains  the  fact,  determined  by  numerous  statistics,  that  the 
mortality  is  lower  in  women  than  in  men. 

Some  of  the  earliest  and  most  marked  manifestations  of  the  disease 
in  alcoholics  are  seen  in  the  nervous  system,  in  the  heart,  and  in  the 
kidneys.  Grave  disturbances  of  consciousness  make  their  appearance 
during  the  very  first  days  :  violent,  even  furious,  delirium,  often  followed 
by  a  transition  into  coma,  particularly  the  ominous  form  of  coma-vigil. 
Protracted  cases  are  particularly  likely  to  assume  the  form  known  as 
"  ataxo-adynamic." 

In  chronic  alcoholic  subjects  the  pulse  becomes  alarmingly  small  very 
early  in  the  disease,  the  tension  diminishes,  and  the  rate  is  greatly 
increased.  There  is  but  little  doubt  that  this  condition  of  the  pulse  is 
due  quite  as  much  to  vasomotor  paralysis  as  to  weakness  of  the  heart- 
muscle. 

The  kidneys  in  alcoholic  patients  regularly  show  early  and  severe 
involvement.  In  some  cases  the  nephritis  manifests  itself  merely  by 
marked  albuminuria  and  the  presence  of  simple  hyaline  casts  in  the 
urine.  Other  cases  present  symptoms  of  the  severest  forms  of  hemor- 
rhagic nephritis,  and  may  terminate  fatally  at  the  end  of  the  first  or 
the  beginning  of  the  second  week  with  pronounced  symptoms  of 
uremia. 

That  alcoholics  are  particularly  liable  to  develop  hypostatic  conges- 
tion of  the  lungs  follows  logically  from  what  has  been  said  in  regard 
to  the  action  of  the  heart. 

Cases  with  chronic  tuberculous  disease  of  the  lungs  also 
frequently  occurred  among  the  material  under  my  observation.  It  may 
be  said  with  certainty  that  persons  suffering  from  this  condition  do  not 
escape  typhus  fever. 

The  development  of  general  miliary  tuberculosis,  or  an  acute  local 
extension  of  the  tuberculous  process  after  typhus  fever,  has  ah'eady 
been  referred  to.  When  this  is  not  the  case,  and  the  local  or  general 
changes  are  not  pronounced,  the  course  of  the  typhus  fever  appears  to 
be  little  influenced  by  the  chronic  tuberculosis. 

THE   EFFECT   OF   CONSTITUTION,   AGE,   AND   SEX. 
The  effect  of  the  constitution — that  is  to  say,  the  general  bodily 
condition  at  the  time  of  infection — on  the  course  of  the  disease  has 
frequently  been  touched  upon.     It  has  been  stated  that  weak,  badly 


566  TYPHUS  FEVER. 

nourished,  debilitated  individuals  arc  particularly  prone  to  be  attacked, 
and  we  may  add  that  such  iudividuals,  as  a  rule,  show  dimiuishcd 
powers  of  resistance.  Vigorous,  well-nourished  individuals  with  normal 
hearts  arc  better  able  to  resist  the  effects  of  typhus  fever,  just  as  they 
better  withstaud,  all  acute  processes. 

On  the  other  hand,  very  corpulent  persons,  even  when  not  alcoholic, 
withstand  the  disease  badly,  just  as  they  do  typhoid  fever.  The  heart 
and  the  vasomotor  system  in  these  iudividuals  seem  to  find  esj)ecial 
difficulty  in  resisting  the  effects  of  the  toxin. 

Sex,  per  se,  does  not  appear  to  have  any  marked  influence  on  the 
course  of  the  disease.  It  is  true  that  in  all  epidemics  the  influence  of 
sex  shows  itself  to  a  marked  degree  in  the  circumstance  that  the  severity 
of  the  disease  and  Kability  to  death  are  distinctly  greater  in  men  than  in 
women,  but  the  cause  of  this  lies  in  the  fact  that  women  are  much  less 
exposed  to  unfavorable  external  conditions  ;  for,  first,  they  are  less  con- 
stantly engaged  in  the  struggle  for  existence ;  and  secondly,  the}'  are 
not,  as  a  rule,  addicted  to  vice,  especially  that  of  alcoholism. 

The  differences  in  regard  to  age  are  distinctly  less  marked  in  typhus 
than  in  typhoid  fever.  This  will  be  reverted  to  later  in  speaking  of  the 
prognosis.  For  the  present  I  shall  confine  myself  to  a  few  remarks 
on  the  manifestations  of  the  disease  in  infancy  and  old  age. 

Typlius  Fever  in  Old  Age. — The  effect  of  old  age  makes  itself 
felt  as  early  as  the  fortieth  year ;  after  the  fiftieth  year  it  becomes  so 
important  a  factor  that  almost  half  of  such  patients  succumb  to  the 
disease. 

Typhus  fever  in  old  age  does  not  present  a  typical  clinical  picture, 
such  as  we  see  in  senile  tj'phoid.  A  considerable  proportion  of  the 
large  number  of  young  invalids  in  a  reduced  state  of  health  who  are 
attacked  by  the  disease  have  a  comparatively  low,  irregular  fever  from 
the  beginning  of  the  attack.  In  older  persons,  on  the  other  hand,  very 
high  temperatures  are  not,  according  to  my  experience,  by  any  means 
uncommon.  It  may  at  least  be  said  that  older  persons  are  less  likely 
to  have  a  high  continuous  or  remittent  continuous  fever  of  long  dura- 
tion, and  present  rather  an  u'regular  temperature-curve  with  marked 
elevations  and  depressions. 

On  the  other  hand,  in  old  people  the  disease  exerts  an  early  and 
pronounced  influence  on  the  circulatory  and  respiratory  organs.  During 
the  first  week  of  the  disease,  during  even  the  first  days,  aged  individuals 
present  symptoms  of  failing  circulation  ;  the  pulse  is  small,  rapid,  and 
of  low  tension  ;  a  morning  pulse  of  120  and  an  evening  pulse  of  140 
are  not  at  all  uncommon. 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS  OF  DISEASE.   567 

As  a  direct  consequence  of  the  cardiac  weakness  and  the  constant 
occurrence  of  severe  catarrh  extending  into  the  finer  bronchioles,  aged 
persons  are  prone  to  develop  lobular  joneuinonia  and  simple  or  inflam- 
matory hypostatic  conditions  in  the  lungs  very  early  in  the  disease. 
Inflammatory  diseases  of  the  lungs  form  a  characteristic  feature  of 
senile  typhus. 

The  central  nervous  system  in  old  persons  early  becomes  involved 
to  a  very  marked  extent.  Although  the  delirium  is  rarely  violent  or 
furious,  but,  rather,  assumes  a  muttering  form,  hebetude  is  likely  to 
show  itself  much  earlier  and  become  much  more  severe  in  old  persons. 
As  early  as  the  middle,  or  toward  the  end,  of  the  first  week  deep  coma 
develops,  with  subsultus  tendmum  and  carphology.  The  form  known 
as  "  ataxo-adynamic  "  is  particularly  liable  to  occur  in  old  persons,  even 
when  they  are  not  alcoholic. 

As  regards  the  kidneys,  I  cannot  say  that  I  have  met  with  more 
numerous  or  more  marked  cases  of  nephritis  in  senile  patients  than  in 
young  and  vigorous  ones. 

On  the  other  hand,  diarrhea  and  dysenteric  affections  of  the  large 
intestine  are  distinctly  more  common  in  old  age  than  in  youth. 

Owing,  probably,  to  the  atrophic  condition  of  the  skin,  the  typhus 
fever  rash  seems  to  appear  somewhat  later  in  old  persons  and  to  reach 
its  complete  development  more  slowly.  On  the  other  hand,  hemorrhagic 
changes  in  the  rash  appear  earlier  and  are  prone  to  be  more  extensive. 
In  the  matter  of  amount  of  rash,  I  do  not  think  there  is  any  great 
difference  between  old  age  and  other  periods  of  life. 

Typhus  Fever  in  Childhood. — Although  the  disposition  to 
typhus  fever  is  not  less  in  childhood  than  in  later  years,  if  we  disre- 
gard the  period  of  infancy,  the  actual  number  of  cases  among  children 
is  comparatively  smaller  than  among  adults.  This  is  due  to  the  fact 
that  typhus  fever  is  practically  confined  to  the  floating  population  and 
to  those  among  the  permanent  residents  who  come  into  immediate  contact 
with  them,  and  that  the  number  of  children  who  come  in  contact  with 
diseased  persons  is  small  in  proportion  to  the  total  number  of  children 
in  the  community. 

Of  the  course  of  typhus  fever  during  childhood  little  is  known. 
Even  the  better  text-books  on  pediatrics  present  little  more  than  general 
accounts  closely  resembling  descriptions  of  the  disease  in  adults. 
Henoch,  who  has  enjoyed  a  wide  experience,  does  not  believe  that 
there  is  any  marked  difference  between  the  course  of  the  disease  in 
children  and  that  observed  in  older  persons. 

One  thing,  however,  is  certain  :  the  course  of  the  disease  in  children 


568  TYPHUS  FEVER. 

is  usuallv  more  rapid  and  verv  iniu'li  more  favorahk'  than  in  adnlts.  In 
the  great  majority  ot"  oases  the  disease  terminates  between  the  eij2;hth  and 
the  twelfth  day.  A  (hu-ation  of  from  fifteen  to  seventeen  days,  whieh  is 
nsnal  in  severe  and  moderately  severe  cases  among  adults,  is  distinctly 
rare  in  childhood. 

That  the  average  course  of  the  disease  in  childhood  is  mild  is  shown 
by  the  deiith-rate,  which  is  from  5  per  cent,  to  7  per  cent. ;  whereas  in 
adults  it  is  at  least  2  J  or  3  times,  and  in  old  age  10  times,  as  great. 

It  is  worthy  of  note  that  the  severity  of  the  disease  shows  marked 
variations  in  the  diiferent  ages  of  childhood.  The  severest  cases  are 
found  in  very  young  children  up  to  the  lifth  year ;  the  mildest,  in  chil- 
dren between  the  tenth  and  fifteenth  years,  whereas  children  between 
the  ages  of  five  and  ten  years  occupy  an  intermediate  position  in  regard 
to  the  severity  of  the  disease. 

That  children  from  five  to  fifteen  years  of  age  are  much  less  severely 
attacked  is  partly  due  to  the  fact  that  the  vital  organs,  especially  the 
circulatory  system  and  the  central  nervous  system,  possess  greater 
powers  of  resistance  to  the  toxins,  and  partly  on  account  of  the  com- 
paratively short  duration  of  the  disease  and  the  greater  rarity  of  com- 
plications. 

Another  fiictor  in  the  low  death-rate  is  the  great  preponderance  of 
cases  of  very  short  duration,  or  absolutely  abortive  cases,  in  childhood. 
Severe  forms  of  the  disease,  such  as  are  observed  in  adults,  especially  the 
so-called  fulminating  forms  combined  with  coma-vigil,  are  distinctly  rare 
among  children. 

The  beginning,  the  course,  and  the  defervescence  of  the  fever  in  well- 
marked  cases  do  not  present  any  marked  differences  from  those  observed 
in  adults.  The  temperature-curve  may,  even  iii  children,  attain  a  con- 
siderable height — 41°  C.  and  over — and  may,  during  the  fastigium, 
assume  the  form  of  a  continued  or  continued  remittent  fever. 

The  pulse  is  almost  always  extremely  rapid,  but  usually  retains  a 
good  tension.  Alarming  cardiac  weakness  occurs  almost  exclusively  in 
children  who  are  debilitated  from  the  effects  of  other  diseases  or  the 
miserable  conditions  amid  which  they  live. 

Although  fatal  paralytic  symptoms  are  comjiaratively  rare,  irritative 
nervous  phenomena  occur  more  frequently  and  are  more  violent  in  chil- 
dren than  in  adults  who  had  been  healthy  before  being  attacked  by  the 
disease.  Children  are  more  frequently  attacked  by  convulsions  during 
the  rise  or  at  the  height  of  the  fever,  and  the  delirium,  restlessness,  and 
noisiness  in  severe  cases  among  children  are  quite  as  marked  as  are  the 
same  symptoms  obsers^ed  in  adults. 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS  OF  DISEASE.    569 

ConjuiictivitLs,  laryngitis,  and  catarrhal  bronchitis  occur  regularly 
and  often  assume  alarming  proportions  in  children.  Lobular  and  lobar 
pneumonia  are  quite  as  common  as  in  adults,  but  hypostatic  consolidation 
is  distinctly  more  rare. 

The  appearance  of  the  tyi)hus  eruption  is  pra(!tically  the  same  as  in 
adults  of  youthful  and  middle  age.  In  children,  as  in  adults,  the 
abundance  of  the  rash  unquestionably  varies  widely  in  different  epi- 
demics, and  this  is  probably  the  reason  that  certain  authors  (Griessinger) 
regard  the  absence  or  scanty  development  of  the  eruption  as  particularly 
common  among  children.  In  the  same  way  the  different  epidemics  vary 
widely  m  regard  to  petechial  transformation  of  the  rose-spots,  both  in 
children  and  in  adults,  although  the  rare  transformation  of  the  purely 
macular  rash  into  small  papules  or  even  circinate  patches  appears  to  be 
somewhat  more  frequent  in  children  than  in  adults. 

Cancrum  oris,  which  claimed  many  victims  among  the  children 
during  epidemics  of  former  times,  has  now  become  so  rare  that  it  may 
practically  be  passed  over  in  silence. 

Decubitus  is  distinctly  less  frequent  in  children  than  in  adults. 

DURATION  OF  THE  DISEASE  AND  PERIOD  OF  CONVALESCENCE. 

Having  sufficiently  discussed  the  abridged  and  abortive  forms,  I  will 
now  devote  a  few  paragraphs  to  the  question  of  the  duration  of  well- 
marked  cases  ending  in  recovery — that  is,  the  period  between  the  begin- 
ning of  the  fever  and  the  end  of  defervescence. 

Duration. — The  discrepancy  among  the  statements  of  the  older 
authors  in  regard  to  this  is  much  greater  than  among  those  of  the  more 
modern  ones,  probably  because  many  infectious  diseases,  especially 
typhoid  and  relapsing  fever,  were  not  properly  distinguished  from 
typhus  fever. 

The  views  of  modern  authors  exhibit  an  astonishing  unanimity. 
Almost  all  give  as  the  average  the  shorter  duration  that  has  already  been 
mentioned.  For  a  well-marked  case  in  an  adult,  the  average  duration 
may  be  regarded  as  from  twelve  to  seventeen  days ;  or,  to  be  even  more 
exact,  I  should  say  that  the  fourteenth  day,  according  to  my  experience, 
most  frequently  marks  the  end  of  defervescence. 

Cases  in  which  the  fever  lasts  longer  than  the  eighteenth  day  are 
comparatively  few  in  number,  while  an  uncomplicated  case  in  w^hich 
the  end  of  defervescence  is  delayed  beyond  the  twenty-first  day,  in  my 
experience,  is  distinctly  exceptional. 

This  sharp  limitation  and  the  strictly  cyclic  course  of  the  disease  are 
the  principal  points  of  difference  between  typhus  and  typhoid  fever. 


570  TYPHUS  FEVER. 

Murchisou  calculated  that  iu  almost  half  of  all  the  cases  convalescence 
begins  on  the  thirteenth  or  the  fourteenth  day,  antl  in  more  than  three-fourths, 
of  all  cases  between  the  thirteenth  and  sixteenth  days.  These  numbers 
were  obtained  from  an  analysis  of  53  uncomplicated  cases.  In  the  epidemic 
of  1879,  iu  Moabit,  we  succeeded  in  determining  the  duration  of  the  disease 
iu  296  cases,  and  obtained  the  following  instructive  table  : 

Convalescence  began  after — 

1-1  days  in  42  cases 


7  days 

in 

1  ca.so 

8   ■' 

7  cases 

0 

IG  " 

10 

25  •' 

11 

25  " 

12 

35  " 

13 

41   " 

15 

33 

16 

28 

17 

16 

18 

14 

19 

9 

20 

4 

296 

Griessiuger  gives  the  duration  of  milder  cases  as  from  twelve  to  fourteen 
days — that  of  the  majority  of  cases  as  from  sixteen  to  twenty  days.  Jenner 
believed  that  uncomplicated  cases  run  their  course  in  from  fourteen  to  twenty- 
two  days  at  the  most.  Barallier  calculated  the  average  duration  in  698 
cases,  and  found  it  to  be  from  ten  to  twenty-two  days. 

In  uncomplicated  cases  convalescence,  when  not  protracted  by 
sequels,  proceeds  more  rapidl}'  than  the  severity  of  the  clinical  picture 
and  the  condition  of  the  patients  immediately  after  the  end  of  deferves- 
cence would  lead  one  to  expect. 

Condition  of  the  Various  Organs  during  Convalescence. 
— After  a  severe  or  moderately  severe  attack  almost  all  patients,  although 
they  soon  begin  to  feel  quite  comfortable,  are  pale,  debilitated,  and 
usually  very  much  emaciated.  A  loss  of  from  10  to  15  pounds,  which 
in  a  disease  lasting  only  from  two  to  three  weeks  cannot  be  regarded  as 
inconsiderable,  is  not  at  all  uncommon.  In  severe  cases  both  I  and 
other  authors  ^  have  frequently  observed,  even  during  the  first  week 
after  the  disappearance  of  the  fever,  an  additional  loss  of  from  2J  to  5 
pounds,  the  cause  of  which  we  can  at  present  merely  surmise. 

The  greatest  loss  in  weight  occurs  naturally  during  the  height  of  the  dis- 
ease. In  one  of  Rosenstein's  cases  a  loss  of  10  pounds  occurred  between 
the  seventh  and  the  fifteenth  day  of  the  disease.  In  another  the  same 
amount  was  lost  in  the  course  of  four  days.  I  myself  have  not  infrequently 
seen  a  loss  of  from  72  to  12  pounds  in  the  course  of  from  five  to  seven  days, 
and  in  one  case  a  loss  of  I62  pounds  between  the  eighth  and  the  thirteenth 
day  of  the  disease. 

In  a  few  cases,  where  the  attack  had  been  very  severe  and  protracted 
and  the  patients  were  previously  much  reduced  in  health,  I  had  occasion 
to  observe  hydremic  conditions  with  edema  over  the  smaller  joints, 
although  the  urine  was  free  from  albumin. 

1  Herrmami,  Petersb.  med.  Wochensch?'.,  1876,  No.  16. 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS  OF  DISEASE.  571 

During  the  first  week  after  defervescence,  sometimes  as  early  as  the 
third  or  fourth,  and  usually  before  the  tenth  day,  my  patients  were^  as  a 
rule,  allowed  to  get  up,  and,  if  convalescence  was  not  interrupted,  they 
were  usually  ready  to  be  discharged  and  go  back  to  work  after  three  to 
four  weeks. 

This  favorable  course  of  convalescence,  while  partly  due  to  the  short 
duration  of  the  disease,  violent  as  it  is,  is  unquestionably  influenced  to 
a  large  extent  by  the  fact  that  the  organs  of  digestion  are  so  little 
involved  in  the  morbid  process.  For  this  reason  convalescents  in  this 
disease,  more  fortunate  than  those  recovering  from  typhoid  fever,  can 
be  permitted  fully  to  satisfy  their  appetite,  which  returns  before  or 
during  the  period  of  defervescence. 

In  severe  cases,  even  when  the  patients  feel  quite  well,  the  pulse 
remains  during  the  first  or  even  the  second  week  comparatively  small, 
soft,  rapid,  and  so  extraordinarily  sensitive  to  external  conditions  that 
the  slightest  provocation  may  induce  a  considerable  although  transitory 
rise  in  the  frequency.  On  the  other  hand,  in  some  very  feeble  patients 
I  have  seen  a  remarkable  slowing  of  the  pulse — in  one  case  down  to 
40  beats  a  minute — ^accompanied  by  pronounced  retardation.  How  this 
bradycardia,  which  is  also  observed  in  other  infectious  diseases — I 
need  only  mention  typhoid  fever  and  diphtheria — is  produced  I  have 
been  quite  unable  to  determine. 

The  temperature  usually  falls  below  the  physiologic  level  on  the  first 
afebrile  day,  and  remains  subnormal  during  the  first,  and  often  part  of 
the  second,  week  of  convalescence.  It  may  be  extremely  low:  35°  or 
36°  C.  in  the  morning,  with  a  very  slight  evening  rise,  is  not  at  aU  un- 
common. After  the  second  week  the  temperature-curve  gradually 
returns  to  the  normal. 

Lilce  the  pulse,  the  temperature  shows  a  marked  instability  during 
the  first  part  of  convalescence.  Physical  and  mental  disturbances,  so 
slight  as  practically  to  be  imperceptible  to  a  healthy  person,  often  bring 
about  a  sudden  material  rise  lasting  a  short  time,  and  the  fever-curve 
becomes  a  faithful  record  of  any  little  disturbances,  such  as  errors  in 
diet,  etc.  • 

Although  the  nervous  system  in  well-marked  cases  regularly  shows 
such  severe  implication,  the  disturbances,  as  a  rule,  subside  very  quickly. 
A  persistence  of  the  delirium,  especially  during  the  evening  hours,  beyond 
the  time  of  defervescence  is  the  most  frequent  of  these  persisting  dis- 
turbances. I  have  seen  deliri\im  last  in  this  way  from  three  to  four 
days,  and  even  until  the  end  of  the  first  week  of  convalescence. 

In  the  great  majority  of  convalescents,  however,  the  cerebral  func- 


572  TYPHUS  FEVER. 

tioiis  arc  restored  dui-iiig  the  tir.st  days,  often  immediately  after  the  dis- 
appearauee  of  the  fever.  Individuals  who  continue  to  have  delirium  in 
the  eveuino-  during  the  lirst  few  days  usually  exliibit  during  the  daytime 
a  certain  wealoiess  of  mental  activity,  especially  a  loss  of  memory  for 
fonner  events.  The  patient's  recollection  of  his  illness  is  almost  always 
very  limited  in  severe  or  moderately  severe  cases.  Most  patients  remem- 
ber only  the  initial  stage — that  is,  the  days  during  which  the  fever 
begins  to  rise.  They  retain  a  lively  recollection  of  the  agonies  of  that 
period,  and  convalescents  who  have  gone  through  an  attack  of  relapsing 
or  typhoid  fever  affirm  that  the  initial  symptoms  in  these  diseases  are 
not  nearly  so  bad  as  they  are  in  typhus  fever.  These  initial  symptoms 
appear  to  be  comparable  only  to  those  of  small-pox,  judging  from  what 
I  have  learned  from  typhus  convalescents  who  had  formerly  had  the 
former  disease. 

On  the  other  hand,  the  period  of  hyperjiyrexia  and  of  most  intense 
symptoms  leaves  a  blank  in  the  mmds  of  the  majority  of  convales- 
cents from  a  severe  attack.  A  few  of  them  may  remember  one  or  two 
particularly  impressive  events,  such  as  baths,  the  visits  of  the  doctor 
and  his  examinations,  or  attempts  at  flight  that  they  may  have  made 
and  the  measures  adopted  to  prevent  their  repetition.  Others  remember 
only  the  subjects  of  their  early  delirium  and  hallucinations,  and  of  these 
they  retain  so  lively  a  recollection  that  they  continue  to  be  troubled  by 
them  in  their  sleeping  and  waking  moments,  and  even  when  they  are 
fully  conscious  cannot  quite  rid  themselves  of  the  idea  that  there  must 
have  been  some  truth  in  them.  When  it  is  remembered  that  their 
hallucinations  frequently  have  to  do  with  most  unusual  and  distressing 
situations  and  actions,  it  will  not  be  difficult  to  understand  that  they 
may  be  a  source  of  great  distress  and  interfere  seriously  with  convales- 
cence. 

True  psychoses  appear  to  be  rare  during  convalescence.  Mild  melan- 
cholia and  hallucinations  are  sometimes  seen,  and  even  mania  has  been 
observed.  Among  patients  treated  in  Moabit  in  1878  and  1879,  4  cases  of 
mental  disturbance  occurred  during  convalescence.  In  2  cases — 1  in  1878 
and  the  other  1  of  the  3  that  occurred  in  1879 — the  disturbances  immedi- 
ately followed  the  end  of  defervescence.  One  case,  that  of  a  young  girl 
with  delusions  of  persecution,  ended  in  recovery  after  eight  days.  In  the 
case  of  2  men,  the  psychosis  made  its  appearance  later :  in  1  case  toward  the 
end  of  convalescence  ;  in  the  other,  after  his  discharge  from  the  hospital. 
The  former,  who  had  to  be  sent  to  the  insane  asylum  on  account  of  violent 
mania,  exhibited  also  severe  auditory  hallucinations  that  were  undoubtedly 
due  to  the  fact  that  he  had  had  a  bad  otitis  media  with  perforation  of  the 
tympanic  membrane  during  the  height  of  his  illness. 

Severe  organic  lesions  of  the  central  nervous  system  being,  as  has 


VARIATIONS  IN  COURSE  AND  MANIFESTATIONS  OF  DISEASE.   573 

been  suid,  quite  uucominou  during  the  febrile  period,  were  rarely  met 
with  in  disturbances  continuing  during  or  even  after  convalescence. 
Isolated  cases  of  paraplegia  and  hemiplegia  have,  however,  been  observed 
in  every  epidemic.  No  cases  of  the  former  have  ever  been  carefully 
investigated  either  clinically  or  anatomically,  and  it  is  not  even  known 
which  of  them  are  to  be  attributed  to  sjMiial  and  which  to  neuritic  dis- 
turbances. On  the  other  hand,  the  morbid  anatomy  of  the  hemiplegias 
is  much  better  known.  They  have  been  found  to  depend  either  on 
hemorrhages  into  the  brain-substance  or  meninges,  or  on  embolism  and 
thrombosis. 

Paralysis  of  individual  muscles  or  groups  of  muscles,  or  of  a  single 
extremity,  is  quite  as  uncommon  as  hemiplegia.  Of  the  muscles  in  the 
upper  extremity,  the  deltoid  appears  to  be  most  frequentl}'  attacked ;  on 
the  trunk,  the  serratus  magnus  ;  and  in  the  leg,  the  extensor  muscles  of 
the  thigh.  Whereas  hemiplegia,  being  due  to  an  organic  lesion,  is 
usually  very  slow  to  disappear  or  even  remains  incurable,  palsies  of 
individual  muscles,  as  a  rule,  disappear  much  more  quickly,  showing 
that  they  are  probably  of  a  neuritic  nature. 

A  much  more  common  event  than  paralysis  during  convales- 
cence is  neuralgia,  which  is  often  very  distressing,  particularly  the 
neuralgic  pains  in  the  toes  and  soles  of  the  feet  already  referred  to. 
They  sometimes  make  their  appearance  during  the  latter  part  of  the 
febrile  period,  and  persist  for  a  variable  length  of  time  during  convales- 
cence. Although  I  have  seen  them  disappear  by  the  end  of  the  first 
week,  I  have  also  known  them  to  last  two  or  three  weeks.  Among  the 
rarer  forms  of  neuralgia  I  may  mention  neuralgia  of  the  supra-orbital 
nerve,  which  appears  to  be  more  obstinate  than  the  other  forms  that 
have  been  mentioned.  One  of  our  cases  was  still  suffering  from  the 
condition  at  the  time  of  his  discharge.  Mention  may  also  be  made  of 
neuralgia  in  the  distribution  of  the  brachial  plexus,  which  assumes  a 
very  severe  form,  although,   fortunately,   it  occurs  more  rarely. 

The  nervous  form  of  deafness  usually  disappears  with  the  fever,  but 
disturbances  due  to  disease  of  the  middle  ear  or  other  grave  alterations 
are  likely  to  be  more  obstinate  and  may  end  even  in  permanent  deafness. 

The  changes  in  the  respiratory  organs,  which  so  frequently  form  a 
disturbing  factor  in  the  course  and  duration  of  convalescence,  have 
already  been  referred  to,  but  we  must  once  more  consider  in  this  connec- 
tion the  frequent  occurrence  of  severe  alterations  in  the  lars'ux  during 
many  epidemics.  Even  after  the  fever  has  subsided  they  require  the 
most  careful  and  persistent  treatment,  in  spite  of  which  permanent 
aphonia  and  laryngeal  stenosis  cannot  always  be  avoided. 


574  TYPHUS  FEVER. 

Among  the  severe  complications  of  convalescence  should  bo  men- 
tioned the  various  purulent  and  necrotic  pulmonary  affections  depending 
on  })urulent  perielKMulritis.  As  has  been  stated  in  another  place,  they 
often  lead  to  purulent  effusions,  and  subject  tlie  patient  to  all  the  diffi- 
cultias  and  dangers  of  an  empyema  opi'ratiou. 

The  organs  of  digestion  being  but  little  involved  during  the  height 
of  the  disease,  there  is  but  slight  interference  with  convalescence  to  be 
expected  from  that  quarter.  I  myself  do  not  remember  any  case  of 
this  kind,  but  from  the  reports  of  several  epidemics  it  appears  that 
violent  vomiting,  occurring  after  the  ingestion  of  food,  has  been  observed 
during  tlie  first  week  after  defervescence.  However,  as  a  nmnber  of 
these  cases  presented  certain  symptoms  referable  to  the  central  ner\-ous 
system,  one  cannot  avoid  the  thought  that  the  phenomenon  may  have 
been  of  central  origin. 

In  a  few  instances  patients  were  greiitly  troubled  during  convales- 
cence by  painful  maceration  of  the  gums  associated  with  hemorrhages. 

Inflammation  of  the  salivary  glands,  developing  during  the  febrile 
period  and  continuing  during  convalescence  or  arising  after  the  end 
of  the  febrile  period,  occurs  Mith  variable  frequency  according  to  the 
period  and  mdividual  epidemic.  It  usually  takes  the  form  of  unilateral 
parotitis,  or,  in  very  rare  cases,  of  which  I  have  personally  seen  but 
one,  mflammation  of  the  sublingual  glands.  In  very  feeble  patients  I 
have  met  with  suppuration  of  an  entire  salivary  gland,  with  necrosis  of 
the  connective-tissue  stroma. 

Changes  in  the  skin  are  a  particularly  fruitful  soiu'ce  of  disturbance 
durino-  convalescence.  Many  patients  continue  to  suffer  for  some  time 
after  defervescence  from  gangrene  of  the  ears,  fingers,  toes,  tip  of  the 
nose,  and  skin  of  the  penis  and  scrotum,  arising  during  the  febrile 
period.  In  2  instances  during  the  epidemic  of  1879  we  were  driven 
to  ]ierform  exarticulation  of  gangrenous  toes. 

Xoma  and  hospital  gangrene  have  become  so  rare  that  they  need 
scarcely  be  reckoned  with  during  convalescence. 

Decubitus,  owing  to  the  relatively  short  duration  of  the  disease,  is 
comparatively  rare,  and  is  practically  seen  only  in  the  most  severe  cases. 
It  mav,  however,  assume  such  marked  proportions  that  we  cannot  believe 
it  to  1)0  entirely  due  to  pressure  and  soiling  of  the  affected  parts,  but  it 
must  be  assumed  that  trophic  disturbances  in  addition  are  operative. 
It  would  appear  that  the  form  that  I  have  described  in  connection  with 
many  cases  of  typhoid  fever,  and  designated  as  subcutaneous  phleg- 
monous decubitus,  is  also  comparatively  more  frequent  than  any  other  in 
typhus  fever.     Without  producing  any  marked  pain  or  even  any  abuor- 


PROGNOSIS  AND  MORTALITY.  575 

mal  sensation,  a  macular,  yellowish-red  or  bluish-red  discoloration  of 
the  skin,  with  more  or  less  extensive  induration  and  infiltration  of  the 
subcutaneous  cellular  tissue,  develops  over  the  nates,  in  tlie  lower  sacral 
region,  or  even  in  the  depths  of  the  fold  between  the  buttocks.  After  a 
few  days  one  or  two  small  openings  appear  in  the  middle  of  the  dis- 
colored area  and  discharge  a  thin,  dirty-colored  pus.  If  the  openings 
are  enlarged  by  incisiou  or  the  diseased  portion  of  the  skin  undergoes 
gangrenous  suppuration,  as  not  infrequently  happens,  a  surprisingly 
large  quantity  of  pus  containing  shreds  of  necrotic  tissue  is  evacuated, 
and  a  large  cavity,  extending  in  all  directions  under  the  sound  skin,  is 
revealed,  which,  although  it  rarely  extends  deeper  than  the  cellular 
tissue,  may  take  a  long  time  to  heal. 

The  ordinary  form  of  decubitus  is  more  often  followed  by  a  deeper 
destructive  process  going  on  to  necrosis  and  sequestration  of  bones, 
particularly  in  the  sacrum  and  coccyx,  and  also  in  the  scapula  afid  the 
trochanters. 

Closely  related  to  actual  decubitus  there  occurs  furunculosis  of  the 
gluteal  region  and  adjoining  portions  of  the  back.  This  complication, 
which  is  not  very  uncommon,  often  occasions  great  suffering  and  con- 
siderably protracts  the  period  of  convalescence.  Occasionally,  I  have 
also  met  with  furuncles  in  other  regions  or  distributed  over  the  entire 
body. 

Once  or  twice  I  had  the  same  experience  that  has  been  mentioned  by 
other  authors — of  erysipelas  following  decubitus,  furuncle,  or  abscess, 
but,  fortunately,  I  never  lost  a  patient  from  this  cause. 

In  the  case  of  a  very  few  convalescent  patients  we  had  a  good  deal 
of  trouble  with  diffuse  phlegmons  beginning  during  the  febrile  period. 
I  have  seen  them  on  the  arms  and  on  the  skin  of  the  abdomen,  and 
believe  that  they  were  due  to  traumatism,  probably  self-inflicted  injuries 
during  delirium.  One  of  these  patients  died  of  septicopyemia  in  the 
fourth  week  of  defervescence. 

VERY    SEVERE    AND    FATAL  CASES,    PROGNOSIS    AND 

MORTALITY, 

The  cases  with  moderately  severe  and  severe  symptoms  in  the  ordi- 
nary sense  having  been  fully  discussed  in  the  general  description  of  the 
clinical  picture,  for  which  they  supplied  the  basis,  will  be  touched  upon 
but  lightly  in  connection  with  prognosis  and  mortality. 

In  this  section  only  those  cases  will  be  particularly  mentioned  that 
present  unusually  severe  symptoms,  and  in  which  the  prognosis  is 
exceedingly  unfavorable  or  absolutely  fatal. 


576  TYPJirS  FEVER. 

In  this  class  we  have  certain  cases  of  very  short  duration,  others 
of  usual  length,  and  even  some  of  ahnoruially  louii-  duration,  all,  how- 
ever, eharacti'rizt'd  hy  unusually  high  fever.  They  are  the  so-called 
hyperpyretic  cases.  In  most  of  them,  after  a  single  violent  chill, 
the  temperature  rises  in  a  short  time,  or  at  one  bound,  or  with  very 
slight  remissions,  to  an  unusual  height,  41°  or  even  42°  C.  being  often 
attiiined  under  such  conditions  as  early  as  the  evening  of  the  second 
or  the  third  day,  and  this  level  is,  as  a  rule,  maintained  for  days  or 
until  the  second  week,  either  with  marked  morning  remissions  or  with 
less  than  the  physiologic  daily  variations.  Such  cases  early  exhibit 
marked  enlargement  of  the  spleen  ;  occasionally,  the  organ  may  become 
palpable  Avith  the  first  appearance  of  the  febrile  symptoms.  Severe 
bronchitis  is  usually  present  from  the  beginning.  Along  with  the 
miusually  high  temperature  there  are  often  an  excessive  increase  in  the 
pulse-rate  and  an  alarming  diminution  in  the  tension. 

In  almost  all  the  cases  the  central  nervous  system  becomes  involved 
very  early  :  violent  delirium  on  the  first  evening,  rapidly  developing 
hebetude,  with  subsultus  tendinum  and  carphology,  going  on  to  the  deejicst 
coma,  in  wliich  the  majority  of  the  patients  die  between  the  ninth  and 
eleventh  days,  sometimes  after  an  excessi\'e  preagonic  rise  in  the  tem- 
peratiu'c  (Fig.  59).  In  a  smaller  number  of  the  hypeii^yretic  cases  the 
fatal  termination  is  preceded  by  an  imusual  drop  in  the  temperature,  as 
shown  in  Fig.  60.      Recovery  in  these  cases  is  exceedingly  rare. 

Cases  beginning  with  hyperpyrexia  and  running  an  unusually  pro- 
tracted course  to  a  fatal  termination  are  much  less  frequent  than  those 
just  described.  The  temperature-curve  frequently  presents  marked 
variations  during  the  course  of  such  cases.  At  first  it  is  excessively 
high,  then  it  fiills  to,  or  even  below,  the  normal.  I  have  seen  cases 
belonging  to  this  group  (Fig.  69)  in  which  death  was  delayed  until  the 
second,  or  even  the  middle  of  the  third,  week,  and  the  temperature  con- 
tinued excessively  low  for  days  or  weeks  before  the  fatal  termination. 

Closely  related  to  this  group  is  a  variety  characterized  by  unusual 
severity  and  almost  constantly  fatal  termination,  in  which  the  temper- 
ature continues  comparatively  low  throughout  the  duration  of  the 
disease. 

Subfebrile  and  Afebrile  Cases. — True  afebrile  cases,  such  as 
occur  in  typhoid,  appear  to  be  extremely  rare  in  typhus  fever.  I  have 
not  seen  a  single  definite  case  of  the  kind,  nor  do  I  find  mention  of 
them  by  the  most  experienced  authors.  On  the  other  hand,  it  quite 
commonly  happens  in  the  cases  that  I  am  now  considering  that  the 
temperature  during  the  entire  period  of  the  disease  does  not  exceed  40° 


PROGNOSIS  AND  MORTALITY. 


577 


or  even  39°  C.  This  is  observed  particularly  in  older  individuals  or  in 
young  persons  whose  strength  has  been  reduced  by  poverty,  vice,  or 
chronic  disease  before  their  infection  with  typhus. 

Instead  of  a  general  descriptiou  of  this  variety,  which  has  never  been 


fully  described,  I  will  give  three  temperature-charts  with  short  notes  of  the 
corresponding  case  histories. 

The  first  case  (Fig.  70)  was  that  of  a  feeble  old  man,  sixtv-three  years 
ot  age,  who  for  months  before  he  was  taken  ill  had  lived  amid  the  'most 
destitute  circumstances.  His  illness  began  with  a  series  of  slight  chills,  after 
which  the  temperature  gradually  rose,  although  it  did  not  exceed  39°  C 
except  on  two  days— the  fourth  and  fifth  days  of  the  disease.  With  the 
beginning  of  the  second  week  the  temperature  gradually  and  steadily  beo-an 


578 


TYPHUS  FEVER. 


to  fall  to  the  normal,  with  a  sliirlit  rise  shortly  before  death.     Splenic  enlarge- 
ment was  absent  iluring  the  entire  conr.se  of  the  disease,      liose-spots  were 


Day  of  tlie  disease. 

Ta                      3                     •♦                     5                     6                     7                     8                     9                     10                    11                   12      1 

^ ^ "^+""^ ' -—~-~ — ::—=-:- 

■v5                        li            " 

t-J^                                        ±                    " 

Ja^  A    '  ,    L                                                                         ~r 

^^      *          fy^    I         j^  -»                  "it 

?       -,-     ^-I?     ^           T^                            it" 

*-,    t^        -/                    t      »-«--v    trpl 

pij*  \,4^z    It        ^^^'^  .iiA  I      ^              it 

^      ^               *      ^                                         i^      -I      ^          ■^^-^^r^      ^ 

3°^                                    _     _L           £     dt2               -                   + 

It                                  -           -H     *:T--«rP                         - 

"    ^                Jlu'^                                          t 

2     »   i                        J 

-^                       X,%/  *                 ^ 

37 Z-'^  2  1       lu  2 

_+-                                                     _ ITTl        ~I 

^  ^^Aw'^ 

^^T" 

_      *j^ 

36                                                                                                                                                                                         1                                           •- 

.:        "               ~ ■ 

riin 

t     .           _..i=»=  __„    = 

Fig.  70.— Male,  aged  sixty-three.     Fatal  termination  with  relatively  low  fever. 

present  iu  small  numbers  and  were  very  indistinct ;  but,  on  the  other  hand, 
numerous  petechise  made  their  appearance  early  among  the  roseola  lesions. 


Day  of  the  disease. 


Fig.  71. 


-Male,  aged  thirty.    Temperature  was  relatively  low  from  the  very  beginning,  and  during 
the  last  week  fell  below  the  normal. 


PROGNOSIS  AND  MORTALITY. 


579 


A  considerable  quantity  of  albinnin  was  found  in  the  urine  from  the  third 
day  until  death.  Coma  developed  on  the  second  day,  accompanied  hy  sub- 
sultus  teudinum,  carphology,  and  muttering  delirium,  and  continued  until 
death. 

The  history  of  the  second  case,  that  of  a  laborer,  thirty  years  of  age,  is 
even  more  remarkable  (Fig.  71).  The  highest  temperature,  attained  only 
once  during  the  entire  course  of  the  disease,  was  89.1°  (J.,  and  from  the  seventh 
to  the  fourteenth  day,  when  death  occurred,  the  temperatux'e  continued  to 
fall  to  so  marked  a  degree  that  during  the  last  four  days  it  ranged  between 
34°  and  35°,  and  eventually  dropped  to  33.3°  and  32.2°  C.  immediately  before 
death.  In  spite  of  this  unusually  low  temperature  the  patient  continued  in 
violent  delirium,  and  was  entirely  unconscious  until  two  days  before  death. 
He  was  too  weak  to  rise,  and  lay  in  bed  in  a  state  of  constant  restlessness, 
crying  and  yelling,  at  last  quieting  down  and  falling  into  distinct  coma- 
vigil  during  the  last  forty-eight  hours  preceding  death.     For  three  months 

Day  of  the  disease. 


'-^^- 


s4: 


i 


f^- 


It 


-A 


;i 


^^ 


-^ 


I 


ii 


^^ 


M 


Fig.  72.— Male,  aged  thirty-flve.    Fatal  case  with  very  low  temperature.    Febris  exanthematicus 

renalis. 

before  his  admittance  the  patient  had  been  without  a  home,  had  scarcely 
eaten  anything,  and  had  drunk  large  quantities  of  whisky. 

Combemale  reports  2  very  similar  cases  with  a  marked  fall  of  temper- 
ature in  the  last  days,  in  one  case  to  33.7°,  in  the  other  to  33.2°  C.  This 
contribution  is  the  only  one  on  this  subject  found  in  recent  literature,  and 
even  the  oldest  authors,  such  as  Hildenbrand,  refer  to  the  condition  in  very 
indefinite  terms. 

A  third  case  that  I  should  like  to  add  was  that  of  a  man,  thirty-five 
years  of  age,  who  died  on  the  ninth  day  of  the  disease  (Fig.  72).  '  The 
temperature  in  this  case  ran  a  remarkably  regular  and  constant  coui-se  at 
a  comparatively  low  level — between  38°  and  39°  C. — and  nothing  but  the 
excessive  weakness  and  frequency  of  the  pulse,  which  were  present  from  the 
beginning,  suggested  a  fatal  termination.  At  the  time  of  his  admission  the 
patient  had  a  well-marked,  closely  aggregated  roseolous  eruption,  which  on 
the  fifth  day  of  the  disease  rapidly  underwent  almost  complete  hemorrhagic 


580  TYPHUS  FEVER. 

trausforniation.  lu  addition  to  this  he  presented  on  the  day  of  his  admis- 
sion— the  fourth  day  of  the  disease — symptoms  of  severe  hemorrhagic 
nephritis  that  c'ontinue<l  to  ilominate  the  clinical  picture  during  the  remain- 
der of  his  ilhiess.  This  and  simihir  cases,  whicli,  it  must  l)e  admitted, 
are  very  rare,  might  well  be  designated  ''renal  fyphvs,"  in  analogy  to  the 
corresponding  forms  occurring  in  typhoid  fever. 

Fatal  cases  of  shorter  moderately  short  duration,  which  are  described 
by  the  older  authors  under  the  tcnu  typhus  siderans,  vary  in  fre- 
quency in  tlie  ditterent  epidoniics. 

They  appear  to  occur  especially  at  the  beginning  and  during  the 
height  of  otherwise  malignant  epidemics,  particularly  such  as  occur  on 
shii)board,  in  prisons,  during  a  siege,  or  in  badly  managed  annies. 
Hildenbrand,  jNIurchison,  Graves,  and  others  among  the  older  authors 
enjoyed  an  abundant  experience  from  which  to  describe  these  varieties. 
It  was  quite  prevalent  during  Napoleon's  campaigns  and  in  the  Crimean 
war,  especially  among  the  French  and  Russians,  who  were  not  nearly 
so  well  looked  after  in  the  matter  of  health  and  general  conditions  as 
were  the  English. 

This  group  includes  cases  ending  fatally  within  a  few  days  after  the 
appearance  of  the  first  symptoms — usually  between  the  third  and  fifth 
days,  or  even  earlier.  Most  of  them  begin  with  a  violent  chill  and  a 
well-developed  splenic  enlargement.  The  temperature  generally  under- 
goes a  rapid  and  uninterrupted  rise,  during  which  the  patients  complain 
of  the  most  violent  symptoms  :  unusually  severe  headache  and  pain  in 
the  back  and  limbs,  accompanied  not  rarely  by  imcontrollable  vomiting 
and  retching.  The  temperature  usually  reaches  a  great,  and  sometimes 
an  excessive,  height.  As  early  as  the  first  day  the  pulse  is  unusually 
small,  frequent,  and  may  become  irregular  in  volume  and  rhythm 
on  the  second  day.  The  patients,  whose  mental  condition  becomes 
clouded  on  the  evening  of  the  first  day,  either  develop  violent  delirium 
lastmg  until  death  or  sink  into  coma-vigil. 

Death  is  preceded  by  symptoms  of  extreme  cardiac  weakness,  and 
usually  by  an  excessive  temperature — in  one  case  I  saw  a  hyperpyrexia 
of  42.6°  C.  The  specific  eruption  is  not  rarely  absent  or  but  sparingly 
developed ;  to  use  an  expression  of  the  older  physicians,  it  "  sticks 
underneath  the  skin."  Accordingly,  the  diagnosis,  especially  when  the 
duration  is  very  short,  is  particularly  difficult,  and  during  large  epi- 
demics can  be  made  only  by  exclusion  and  by  the  determination  of 
long-continued,  close  contact  with  w^ell-marked  typhus  fever  cases. 

In  this  way  one  can  understand  certain  cases  described  by  reliable 
authors  as  lasting  only  one  or  two  days  or  a  few  hours.  Personally,  I 
have  never  met  -svith  cases  of  such  short  duration.     The  quickest  fatal 


PROGNOSIS  AND  MORTALITY.  581 

case  I  have  had  occasion  to  observe  terminated  in  tlie  nij^lit  l)etween  the 
third  and  fourth  days  of  the  disease. 

I  must  not  omit  to  mention  that  a  majority  of  these  cases  are  char- 
acterized by  marked  albuminuria  from  the  very  bcginninj^,  and  that 
diphtheric  anginas  are  distinctly  more  frequent  than  in  the  other  forms 
of  typhus  fever. 

Among  the  forms  that  almost  always  end  fatally  must  be  included 
the  so-called  hemorrhagic  cases. 

Although  this  variety  always  receives  careful  consideration  in  descrip- 
tions of  the  acute  exanthemata,  but  little  attention  is  devoted  to  it  even 
in  careful  descriptions  of  epidemics  and  in  monographs  on  typhus  fever. 
Exactly  as  in  the  acute  exanthemata,  these  cases  present  a  great  variety 
of  manifestations,  and,  for  external  reasons,  they  may  be  best  divided 
into  the  fulminating  form  and  the  form  having  a  somewhat  longer 
duration. 

Although  cases  of  the  fulminating  hemorrhagic  form  of  typhus  fever 
are  exceedingly  rare  in  comparison  with  those  of  small-pox  of  the  form 
designated  as  purpura  variolosa,  the  two  conditions  nevertheless  possess 
many  points  in  common. 

The  temperature  rises  rapidly  to  a  great  height,  and  other  severe 
initial  phenomena  are  observed.  With  the  first  appearance  of  the  rash — 
in  the  severest  cases  at  the  end  of  the  second  or  beginning  of  the  third 
day  of  the  disease,  before  there  is  any  sign  of  a  rash — numerous  petechise 
make  their  appearance  and  are  immediately  followed  by  extensive  hem- 
orrhages hito  the  skin  and  subcutaneous  cellular  tissue  of  the  trunk  and 
extremities.  The  conjunctivae  are  injected,  and  hemorrhages  from  the 
lips,  tongue,  gums,  and  nose  make  their  appearance.  This  is  followed 
by  ecchymosis  and  softening  of  the  pharyngeal  structures  and  diphtheric 
exudation  or  gangrene  of  the  mucous  membrane.  Soon  hematuria  of 
renal  origin,  with  signs  of  severe  nephritis,  and  also  hematuria  due  to 
hemorrhage  from  the  pelvis  of  the  kidney  and  the  bladder,  are  super- 
added. Many  of  the  patients  early  expectorate  a  serosanguineous  sputum  ; 
there  are  consolidations  of  the  pulmonary  tissues,  sometimes  ending  in 
gangrene  of  the  lung.  Intestinal  hemorrhages  and,  in  the  case  of 
women,  abundant  metrorrhagia  complete  the  horrible  clinical  picture,  to 
which  the  older  authors  were  in  the  habit  of  applying  the  term 
"Faulfieber." 

In  most  cases  the  appearance  and  development  of  the  hemorrhages 
are  accompanied  by  a  rapid  fall  of  the  temperature,  which  often  sinks 
to  an  unusually  low  level  just  before  the  end.  For  days  before  death 
it  is  often  impossible  to  feel  the  pulse.     To  this  extreme  prostration  of 


582  TYPHUS  FEVER. 

tlic  ciivnlatorv  organs  is  to  be  attributed,  at  least  in  part,  the  gangrene 
of  the  fingers,  toes,  tip  of  the  nose,  and  ears,  these  organs  often  appearing 
suspiciously  pale,  livid,  and  eold  even  during  the  first  twenty-four  or 
thirty-six  hours. 

Although  the  number  of  these  cases  that  I  have  seen  personally  is 
verv  liiniu'(l,  they  are  iirnily  iinpresscd  on  my  memory.  Hematemesis 
never  occurred  among  my  cases,  and  ap])ears  to  be  rare.  A  case  of 
Christie's  '  appears  to  me  well  worth  (juoting.  A  child,  nine  yeiirs  of 
age,  at  first  presenting  a  typical  rash,  which  later  becjime  markedly 
hemorrhagic,  died  on  the  ninth  day  of  the  disease  in  consequence  of  an 
extensive  hemorrhage  from  the  stomach,  the  source  of  which  was  found 
at  the  autopsy  to  be,  not  a  large  vessel,  as  was  expected,  but  an  extensive 
capillary  oozing. 

The  most  malignant  cases  in  this  grouji — those  that  end  fatally 
during  the  first  days  of  the  disease  before  the  appearance  of  the  true 
typhus  rash — are  comparable,  as  has  been  stated,  to  the  variety  of  small- 
pox known  as  purpura  variolosa.  As  I  have  shown  in  the  discussion 
of  that  disease,^  we  have  to  deal  with  an  affection  that  has  become  hem- 
orrhagic in  the  very  beginning  of  the  initial  stage. 

It  goes  without  saying  that  the  hemorrhagic  process,  which,  strictly 
speaking,  belongs  to  the  typical  course  of  the  disease,  especially  as  regards 
the  cutaneous  changes,  may  become  prominent  during  any  other  stage  of 
the  disease.  Even  then  the  prognosis  is  bad,  although  not  quite  so  hope- 
less as  in  the  form  just  considered.  In  general  the  prognosis  is  more 
favorable  the  later  the  hemorrhagic  process  makes  its  appearance. 

These  cases  also  present,  in  addition  to  the  early  and  marked  hem- 
orrhagic transformation  of  the  specific  roseolous  eruption,  numerous 
independent  petechise,  as  well  as  the  previously  mentioned  extensive 
cutaneous  hemorrhages. 

The  temperature-curve  in  these  cases  is  variable  :  some  cases  are 
characterized  by  hyperpyrexia ;  others  exhibit  an  irregular  febrile 
course,  with  marked  remissions  or  even  intermissions  suggesting  col- 
lapse ;  again,  there  are  cases  in  which  the  appearance  of  the  hemor- 
rhages is  accompanied  by  a  marked  fall  in  the  temperature,  which 
remains  subnormal  and  often  exceedingly  low  until  death. 

These  cases  also  are  characterized  from  the  ver)"^  outset  by  pronounced 
weakness  of  the  circulatory  system,  small,  rapid,  irregular  pulse,  pul- 
monary infarcts,  and  hypostatic  congestion.  In  2  instances  I  observed 
also   intracranial   hemorrhages :    once    into   the   brain-substance  in  the 

^  Glasgow  Jcmr..  Dec,  1888. 

^  See  Curschmann,  "Die  Pocken,"  Ziemsnen^'i  Handb.,  second  edition,  vol.  i. 


PROGNOSIS  AND  MORTALITY.  583 

region  of  the  large  ganglia,  and  another  time  into  the  meninges.  Early 
and  well-marked  alljuminuria  is  a  constant  feature  of  this  variety,  and 
abundant  hemorrhages  from  the  urinary  passages  are  common  occurrences. 
Rapidly  progressing  loss  of  strength  is  a  well-marked  symptom  from 
the  beginning ;  the  patients  soon  become  unconscious  and  many  are  vio- 
lently delirious,  although  the  majority  present  the  so-called  "ataxo- 
adynamic"  form  of  the  disease. 

PROGNOSIS;    MORTALITY. 

General  Consideration  of  the  Mortality-rate. — The  ques- 
tion as  to  the  mortality  of  typhus  fever  in  its  broadest  sense  is  not  easy 
to  answer.  The  older  statistics,  although  extensive,  are  of  no  value, 
because  typhoid  and  relapsing  fever  were  not  distinguished  from  typhus 
fever  with  sufficient  exactness,  and  the  figures  given  are  therefore  too 
low. 

Even  in  later  times,  however,  when  this  distinction  was  more  accu- 
rately made,  discrepancies  are  found  that  cannot  be  attributed  altogether 
to  variations  in  the  disease,  but  depend  rather  on  errors  of  observation 
and  diagnosis. 

These  errors  usually  result  in  an  excessively  high  estimate  of  the 
mortality,  especially  when,  as  was  the  case  in  certain  regions  and  at 
certain  periods,  medical  men  were  not  sufficiently  trained  to  recognize 
all  the  various  forms  of  the  disease,  especially  the  milder  and  imper- 
fectly developed  forms,  and  therefore  based  their  statistics  exclusively 
on  the  well-developed  and  severe  cases  that  came  under  their  obser- 
vation. 

Again,  although  the  attempt  might  be  made  to  correct  errors  inci- 
dental to  statistics  based  on  a  small  number  of  cases  by  comparison  wdth 
a  large  number  of  reports  derived  from  various  epidemics  occurring  at 
various  times,  it  is  to  be  remembered  that  the  malignancy  of  the  disease 
is  subject  to  the  greatest  variations,  not  only  in  different  localities  and 
at  various  periods,  but  even  during  different  periods  of  the  same 
epidemic. 

Takmg  all  the  difficulties  into  account  as  well  as  possible,  the  mor- 
tality of  typhus  fever  in  general  may  be  placed  at  from  15  to  20  ]3er 
cent.  It  follows,  therefore,  that  typhus  fever  is  one  of  the  most  dan- 
gerous of  infectious  diseases — far  more  dangerous  than  typhoid  fever. 

Some  vague  idea  of  the  nature  of  typhoid  fever  in  GriessiDcer's  time 
may  be  obtained  from  the  statement  of  that  author  that  typhus  fever,  the 
general  mortality  of  which  he  estimated  at  from  15  per  cent,  to  20  per  cent., 
is  "  considerably  less  dangerous  than  typhoid." 


584  TYPHUS  FEVER. 

Murchison,  whose  statistics  on  the  general  mortality  are  most  elaborate 
ami  based  on  the  largest  number  of  cases,  on  the  basis  of  4787  cases  treated 
in  the  London  Fever  Hospital  between  1848  and  18G2,  calculated  the  mor- 
tality at  20.8i>  per  cent.  Among  9485  cases  admitted  to  the  Infirmary  at 
Glasgow  during  a  period  of  eleven  years,  he  reports  a  mortality  of  18  })er 
cent.,  and  among  1870  patients  treated  in  another  Glasgow  hospital  the 
mortality  was  2o6,  or  17.28  per  cent.  After  collecting  the  enormous  number 
of  18,592  cases  observed  by  himself  anil  other  authors,  Murehison  finally 
determined  the  mortality  to  be  18.78  per  cent. 

From  my  analysis  of  the  676  cases  that  I  observed  in  INIoabit  in  the  years 
from  1876  to  1879,  almost  all  of  which  came  from  the  most  destitute  classes 
of  the  population,  I  obtained  the  alarming  figure  of  23.4  per  cent.  The 
distribution  of  the  cases  for  the  three  years  was  as  follows : 

Admitted  in  1876,  148  ;  deaths,  40 — 27  per  cent.  ;  in  1878,  87  ;  deaths, 
22 — 25.8  per  cent.  ;  in  1879,  441  ;  deaths,  97 — 21.8  per  cent. 

A  mortality  of  from  15  to  12  per  cent,  or  even  10  per  cent,  and  less 
has  been  reported  in  a  few  epidemics  of  minor  extent,  characterized  by 
unusually  favorable  conditions.  It  far  more  frequently  happens  that  the 
mortality  rises  above  20  and  as  high  as  30  per  cent.  Such  high  figures 
are  reached  in  epidemics  when  the  social,  and  consequently  the  individual, 
conditions  are  particularly  unfavorable — as,  for  instance,  when  the  disease 
breaks  out  in  times  of  war  or  famine,  on  shipboard,  in  prisons,  and  under 
other  especially  unhygienic  circumstances.  Under  such  conditions  the 
mortality  has  risen  as  high  as  50  per  cent.  Again,  I  may  cite  the  Crimean 
M^ar  and  Napoleon's  campaigns.  In  very  recent  times  reports  of  an 
unusually  severe  form  of  the  disease  have  been  received  from  various 
regions.     Thus,  Dardignac^  calculated  the  mortality  at  36.3  per  cent. 

In  hospitals  a  mortality  of  from  22  to  25  per  cent,  is  quite  common. 
It  is  often  greater  than  it  is  among  the  outside  population  during  the 
same  epidemic,  obviously  owing  to  the  fact  that  a  relatively  large  number 
of  severe  cases  are  admitted.  The  high  mortality  of  21.14  per  cent, 
that  we  had  in  1879  in  Moabit  could  be  brought  do^vn  to  18.8  per  cent, 
if  the  cases  admitted  in  a  moribund  condition  and  those  that  died  before 
the  end  of  forty-eight  hours  were  deducted  from  the  total.  Murehison 
also  states  that  the  mortality-rate  in  his  4787  cases  would  be  reduced 
from  20.89  to  17.9  per  cent,  if  he  were  to  make  the  same  reserva- 
tion. 

The  conditions  that  determine  the  character,  and  especially  the 
malignancy,  of  the  disease  are  as  numerous  as  they  are  variable. 

The  peculiarities  of  the  life-history  of  the  specific  organism  and  the 
reaction  of  the  body  to  this  organism  are  unquestionably  most  impor- 
tant factors,  and  we  cannot  hope  fully  to  understand  these  until  a  more 
thorough  knowledge  of  the  micro-organism  is  obtained. 

^  Depart.  Oise,  1893. 


PROGNOSIS  AND  MORTALITY.  585 

General  external  und  personal  conditions  having  an  influence 
are,  relatively  speaking,  much  better  known. 

Among  the  general  external  conditions  geographic  distribution, 
weather,  and  time  of  year  were,  no  doubt,  formerly  ofmucli  greater 
importance  than  they  are  to-day.  Certain  of  the  older  authors  state 
that  they  observed  a  distinct  increase  in  the  virulence  of  typhus  fever 
in  certain  countries  and  during  certain  seasons  and  weather  conditions, 
but  at  present  we  know  that  such  factors  are  only  indirectly  important  in 
so  far  as  they  affect  the  social  and  personal  conditions  of  the  populations. 

Reference  has  frequently  been  made  to  the  fact  that  great  national 
destitution,  famine,  war,  and  sieges  favor  the  development  and  materially 
increase  the  malignancy  of  the  disease. 

Among  individual  conditions  age  undoubtedly  exerts  the  greatest 
influence  on  the  mortality. 

In  children  and  young  individuals  under  the  age  of  tAventy,  just  as 
in  typhoid  fever,  the  mortality  is  low — not  more  than  from  2  to  5  per 
cent.  It  is  materially  higher  between  the  ages  of  twenty  and  tliirty, 
and  in  severe  epidemics  may  be  doubled  or  more  than  doubled.  Between 
the  ages  of  thirty  and  forty  the  mortality  is  four  times  as  high  as  among 
individuals  of  under  twenty,  and  after  forty  it  rises  to  a  stupendous 
height.  Thus,  in  Moabit  in  1879  almost  two-thirds  of  all  the  deaths 
occurred  in  individuals  over  forty  years  of  age,  although  of  the  entire 
number  of  patients  admitted  only  one-quarter  were  of  this  age.  Approx- 
imately the  same  proportion  has  been  observed  in  other  epidemics. 

There  is  an  interesting  difference  in  the  mortality  in  the  three  periods 
of  childhood.  This  difference  is  sharply  defined  and  has  been  observed 
with  great  regularity,  but  no  satisfactory  explanation  has  so  far  been  offered. 
Children  under  five  years  of  age  are  in  greatest  danger  from  the  disease, 
whereas  the  period  between  ten  and  fifteen  years  exhibits  the  most  favorable 
mortality.  In  the  latter  period  the  mortality  ranges  between  0.5  and  4 
per  cent,  whereas  among  children  under  five  it  varies  from  6  to  12  per  cent. 
The  intermediate  class,  comprising  children  between  the  ages  of  five  and  ten, 
occupies  a  corresponding  intermediate  position  as  regards  the  mortality  (4  to  7 
per  cent.).  In  illustration  of  this  point  statistical  tables  of  Murchison  and 
Gratzer  are  added.  The  former  collected  his  statistics  from  the  records  of 
563  children  in  the  London  Fever  Hospital : 

Admitted.  Died.  Per  cent. 

Under        5  years 17                   3  17.65 

Between    5  and  10  years         ....       183  14  7.65 

"         10    "     15  "    "       363  18  4.95 

Griitzer  based  his  calculations  on  158  cases  of  children  in  the  Breslan 
epidemic  of  1869  : 

Admitted.  Died.  Per  cent. 

Under        5  years 15                  1  6.66 

Between    5  and  10  years 42  2  4.76 

"         10    "     15  ■    "       101                   1  0.99 


586  TYPUUS  FFA'ER. 

To  illustrate  the  luorrality  among  all  ages  I  give  two  tables  leased  ou 
very  large  figures,  one  l)y  Murchisou,  based  ou  8506  cases  admitted  to  the 
London  Fever  Hospital  during  teu  years,  and  a  later  one  by  Guttstadt, 
based  on  5545  cases  admitted  to  Prussian  hosj)itals  during  the  years  from 

187i?  to  18S0. 

The  ibllowiiig  are  the  statistics  of  Murchisou  : 

Age.                                  Number  ii(lniitto(l.        Died.  Per  pent 

Under        5  yoiirs 17  3  17. Go 

Between    5  "and  10  veai-s 183  14  7.65 

"         10    '■    15  '  "      303  18  4.95 

"         15    '•    "20     "      54G  20  4.76 

"         20    '■    25     "      495  47  9.05 

"         25    "    30     "      343  52  15.15 

30    "    35     "      323  55  17.02 

"         35    "    40     "      270  89  32.90 

"         40    "    45     "      292  87  29.79 

"         45    '•    50     "      212  83  39.15 

"         50    "    55     "      150  78  52.00 

"         55    "    00     "      100  51  51.00 

"         00    "    05     "      88  49  55.08 

"         05    "    70     "      42  28  00.06 

70    "    75     "      24  17  70.83 

75    "    80     "      0  5  83.33 

Over                     80     "      2  2  100.00 

Age   unknown _50  ^1  22.00 

3506  715 
Guttstadt' s  statistics  are  : 

Males.  Females. 

Per  cent.  Per  cent. 

Under      10  years 2.2  3.3 

Between  10  and  15  vears 3.0  1.5 

"         15    "    20  ■   '•      5.2  4.5 

"         20    "    30      "      8.2  10.1 

80    "    40      " 10.0  11.2 

"         40    "    50      "      31.9  20.2 

50    "    00      " .  43.7  35.5     . 

Over                      00       "      57.1  45.2 

My  own  material,  consisting  of  410  cases  treated  in  1879  in  the  lazaretto 
at  Moabit,  yielded,  according  to  the  figures  of  my  assistant  Salomon,  the 
following  mortality  for  the  different  ages  : 

Per  cent. 

From  10  to  20  vear.s 2.50 

"      20  "  30  '  "       5.49 

"      30  "  40     "      20.00 

"      40  "  50     "      48.53 

"      50  "  00     "      03.03 

"      00  "  70     "      02.50 

"      70  "  80     "      100.00 

The  oft-repeated  statement  that  the  effect  of  age  on  the  jirognosis  is 
to  be  attributed  to  the  diminished  powers  of  resistance  against  the  micro- 
organism and  its  toxins,  just  as  in  the  other  acute  infectious  diseases,  is 
a  mere  platitude.  A  much  more  tangible  reason  for  the  rapid  rise  of 
mortality  after  the  age  of  forty  is  to  l)e  found  in  the  cardiic  weakness 
that  is  much  more  prominent  during  this  period  of  life  and  in  the 
pulmonary  complications,  especially  hypostatic  inflammations,  directly 
dependent  upon  it. 


PROGNOSIS  AND  MORTALITY.  587 

The  high  mortality  during  the  period  between  thirty  and  forty,  in 
proportion  to  that  observed  in  other  acute  infectious  diseases,  is  prob- 
ably due  to  the  fact  that  typhus  fever,  which  preferably  attacks  the 
poorer  classes,  generally  selects  those  individuals  who  have  suifered 
most  in  the  struggle  for  existence  and  whose  strength  has  l)ecn  sapped 
by  worry,  vice,  and  general  destitution. 

As  regards  the  remarkable  differences  in  the  mortality  observed 
during  the  three  periods  of  childhood,  we  still  lack  the  necessary  data 
to  offer  an  explanation.  It  might  be  said  of  the  period  between  the 
tenth  and  the  fifteenth  year  that  the  clinical  material  is  selected,  inas- 
much as  only  children  of  good  constitution  and  good  powers  of  resist- 
ance attain  that  age ;  and  as  regards  the  first  period,  the  death-rate  is 
perceptibly  increased  by  the  fact  that  the  children  are  still  contending 
with  the  difficulties  of  early  feeding  and  with  inherited  weakness  and 
the  like,  and  have  not  yet  developed  a  strong  constitution. 

Next  in  importance  to  the  age  are  occupation  and  mode  of  life. 
The  theory  that  certain  conditions  of  life  and  occupations,  owing  to  some 
inherent  favorable  or  unfavorable  conditions,  exert  a  peculiar  influence 
on  the  prognosis  has  been  abandoned  in  the  light  of  more  recent  experi- 
ence. The  effect  of  these  two  factors  can  only  be  indirect,  and  they  are 
of  influence  only  in  so  far  as  they  determine  bodily  and  mental  over- 
exertion, insufficient  or  improper  feeding  and  modes  of  life,  and  general 
hardships,  or  as  they  favor  the  development  of  chronic  disease,  and  the 
acquirement  of  passions  and  vices,  especially  alcohoHsm. 

The  marked  influence  to  be  attributed  to  poverty,  disease,  and  vice  in 
general  is  illustrated  by  one  of  Murchison's  tables,  in  which  the  3506  patients 
admitted  to  the  London  Fever  Hospital  are  divided  into  three  classes  :  First, 
those  in  good  circumstances  ;  second,  those  in  moderately  good  circumstances  ; 
third,  the  poor.     The  results  are  as  follows : 

Admitted.  Died.  Per  cent. 

First   class 94  15  14.89 

Second  " 2674  497  18.6 

Third     " 738  204  27.64 

The  mortality,  considered  with  reference  to  social  status  and  occupa- 
tion, is  found  to  be  greatest  wherever  these  either  permanently  or  tempo- 
rarily necessitate  a  combination  of  bodily  and  mental  overexertion  with 
worry,  care,  and  destitution.  Tradesmen  and  day  laborers  attacked  by 
the  disease  while  out  of  work  and  without  a  home,  travelling  about  the 
country  in  search  of  work  or  living  in  asylums,  huts,  or  overcroAvded 
tenements,  die  in  very  great  numbers.  Persons  on  shipboard,  in  camps, 
and  in  cities  after  a  long  siege  are  also  under  similar  conditions  of 
unfavorable  prognostic  omen.      For  many  years  "febris  casfrensis  pete- 


588  TYPHUS  FEVER. 

chialis,"  "  typhus  carceruin,"  aud  ''febris  nautica "  have  boeu  known 
as  the  most  dreaded  forms  of  the  disease. 

lu  reg-ard  to  the  constitution,  tliose  M'ho  are  naturally  deficient  in 
this  respect  or  iiave  injured  tlieir  health  by  bad  habits  and  an  irregular 
and  dissipated  mode  of  life  are,  e%'en  without  regard  to  age,  most  likely 
to  succumb  to  the  disease.  Again,  alcoholism  exerts  a  most  baneful 
influence  :  50  per  cent,  is  not  too  high  an  estimate  for  the  mortality  of 
drmikards,  even  in  those  between  the  ages  of  twenty-five  and  forty. 

That  chronic  diseases,  as  tuberculosis,  syphilis,  malarial  cachexia, 
chronic  gastric  and  intestinal  affections,  and  recent  recovery  from  severe 
acute  infectious  diseases,  appreciably  augment  the  danger  of  typhus  fever 
need  hardly  be  mentioned. 

That  bodily  and  mental  overexertion  exercises  a  marked  influence  on 
the  prognosis,  even  when  the  individuals  possess  a  strong  constitution, 
are  well  fed  and  of  a  favorable  age,  is  shown  by  the  fact  that  in  all  the 
more  extensive  epidemics  an  unnsually  large  number  of  victims  were 
drawn  from  among  physicians,  hospital  attendants,  ministers,  and  officials 
in  public  institutions. 

Whether  mental  depression,  worry,  and  excitement  without  accom- 
panying bodily  disturbances  tend  to  increase  the  danger  from  the  disease, 
as  has  been  insisted  upon  particularly  by  the  older  authors,  cannot  with 
certainty  be  determined,  because  it  is  rarely  possible  to  estimate  their 
influence  apart  from  the  above-mentioned  factors. 

x^ot  only  the  surroundings  of  the  patient  before  he  was  attacked,  but 
also  the  conditions  under  which  he  lives  during  his  illness,  have  an 
important  bearing  on  the  mortality.  Proper  treatment  unquestionably 
lowers  the  mortality-rate.  Among  experienced  hospital  physicians  it 
is  generally  accepted  that  any  delay  m  removing  the  patient  from  his 
miserable  social  conditions  into  the  more  favorable  surroimdings  of  the 
hospital  seriously  affects  the  prognosis. 

The  effect  of  sex  on  the  mortality  of  typhus  fever  is  purjDosely 
treated  at  the  end  of  our  remarks  on  the  prognosis,  because  it  apparently 
does  not  exert  any  direct  influence  upon  it.  The  lower  mortality 
observed  among  women  is  explained  by  the  circumstance  that  the  female 
sex  is  much  less  exposed  to  the  deleterious  influences  that  are  naturally 
incident  to  the  life  of  man.  In  times  of  hardship,  famine,  and  siege, 
wlicn  the  two  sexes  share  equally  in  want  and  miseiy  and  the  epidemic 
spreads  to  the  permanent  population,  the  differences  in  the  mortality 
practically  disappear. 

Guttstadt's  talile,  given  on  paire  586,  shows  clearly  the  difference  in  the 
mortality  of  the  two  sexes,  especially  during  advanced  age.     In  the  Infirm- 


PROGNOSIS  AND  MORTALITY.  589 

ary  at  Edinburgh,  Peacock'  lost  114  out  of  748  patients,  377  of  whom  were 
men  and  371  women.  Among  the  fatal  cases  69 — 18.3  per  cent. — were 
men  and  45 — 12.5  per  cent. — women.  In  1847,  during  a  severe  epidemic 
in  Glasgow,  32.4  per  cent,  of  the  men  and  only  20.7  per  cent,  of  the  women 
succumbed  to  the  disease.  The  mortality  among  Murchison's  3506  patients, 
already  discussed  from  other  points  of  view,  among  whom  there  were  almost 
as  many  men  as  women,  was  21.  IH  per  cent,  for  the  men  and  19.61  per  cent, 
for  the  women. 

Whether  certain  races  possess  a  diminished  power  of  resistance  to  the 
disease  is  a  difficult  question  to  determine,  and  we  have  no  means  of 
judging  whether  any  particular  race  is  more  susceptil)le  to  infection 
than  another.  The  fact  that  where  the  colored  and  white  races  are 
attacked  side  by  side  a  greater  number  of  the  former  succumb  to  the 
disease  is  probably  due  to  the  circumstance  that  they  are,  generally 
speaking,  placed  amid  much  more  unfavorable  external  and  social 
surroundings. 

Of  no  less  importance  than  the  above-mentioned  factors  which  deter- 
mine the  general  mortality  are  those  features  of  a  case  which  need  to  be 
considered  in  judging  of  the  probable  course  and  outcome. 

The  question  whether  the  mode  of  onset,  and  the  severity  of 
the  symptoms  during  the  stage  of  invasion  afford  any  clue  to  the 
future  course  of  the  disease  has  received  different  answers  from  different 
authorities.  High  fever  and  grave  general  manifestations  durmg  this 
time  certainly  possess  no  prognostic  significance.  They  are  just  as 
likely  to  usher  in  a  short  or  even  an  abortive  case  of  the  disease  as  a 
severe  one.  On  the  other  hand,  it  may  be  said  that  a  mild  stage  of 
invasion  almost  always  indicates  that  the  subsequent  course  of  the  dis- 
ease will  also  be  mild.  Very  rarely,  chiefly  in  the  senile  forms,  it  may 
happen  that  a  comparatively  quiet  and  apparently  mild  initial  stage  leads 
to  a  protracted  illness  with  a  fatal  result. 

Duruigthe  subsequent  course  of  the  disease  certain  general  Symp- 
toms and  the  action  of  individual  organs  and  systems  exert  a 
decisive  influence  on  the  prognosis. 

Among  these  features,  the  most  conspicuous  manifestation  of  the 
fever,  the  elevation  in  temperature,  is  undoubtedly  of  great  prognostic 
importance,  although  its  significance  has  in  many  respects  been  exag- 
gerated. 

Very  high  temperature  during  the  initial  stage  or  during  the  first 
week  does  not  absolutely  justify  the  expectation  of  a  severe  illness  or 
even  a  fatal  termination.  On  the  other  hand,  the  prospect  is  not  bright 
if  a  continued  or  continued  remittent  fever,  with  a  very  high  average 

^  Quoted  by  Murchison. 


590  TYPHUS  FEVER. 

tenii)eraturo,  persists  after  the  first  \voek.  Conversely,  a  favorable  prog- 
nosis based  on  the  mere  iall  in  the  temj)eratnre  after  the  first  week  is 
not  justifiable.  It  has  been  sliown  by  several  examples  (Figs.  (j9  and 
71)  that  fatal  protracted  cases  may  show  a  persistently  low  temperature 
during  the  last  few  days,  or  even  a  week,  before  death,  during  which 
time  Other  ominous  symptoms  continue  without  abatement. 

It  is  not  possible  to  state  with  certainty  whether  a  fall  of  tempera- 
ture on  the  seventh  day,  which,  according  to  A\' under] ich,  is  typical  of 
a  fa\()i'ablc  case,  may  be  considered  a  favorable  prognostic  sign.  Per- 
sonally, I  have  rarely  met  with  this  phenomenon.  On  the  other  hand, 
marked  remissions  and  intermissions  occurring  early  are  undoubtedly 
of  favorable  omen. 

The  action  of  the  circulatory  organs  is  of  far  greater  importance 
in  the  prognosis,  and  affords  a  reliable  means  of  judging  the  course 
of  the  disease.  As  has  been  stated  elsewhere,  the  pulse  in  typhus 
fever,  not  only  in  women,  children,  and  old  persons,  but  also  in  vigor- 
ous men,  is  often  proportionately  veiy  rapid,  both  early  in  the  course 
of  the  disease  and  during  the  entire  febrile  period,  the  phenomenon 
being  in  accord  with  the  violence  of  the  mode  of  onset  and  presentmg  a 
certain  contrast  to  what  is  observed  in  typhoid  fever.  The  pulse-rate 
itself,  although  it  indicates  the  earlv  and  distinct  involvement  of  the 
heart,  is  of  even  less  importance  than  other  qualities  of  the  pulse,  espe- 
eiallv  volume,  tension,  and  regularity.  The  earlier  the  pulse  becomes 
soft  and  easily  compressible,  or  unequal  and  irregular,  the  more  unfa- 
vorable the  prognosis.  Early  irregularity  of  the  pulse  I  believe  to  be 
an  especially  useful  sign.  It  must,  however,  always  be  remembered 
that  reeoveiy  has  been  known  to  occur  even  in  cases  in  which  the  pulse 
was  barely  perceptible  for  days,  and  so  rapid  that  it  could  hardly  be 
counted. 

Next  in  importance  to  the  behavior  of  the  circulatory  system  from 
a  prognostic  point  of  view  is  that  of  the  nervous  system,'  It  is  evident 
that  severe  disturbances  of  the  central  nervous  system  indicate  that  the 
effect  of  the  toxin  has  been  particularly  marked  or  that  the  individual's 
power  of  resistance  is  much  reduced ;  and  thus  the  earlier  the  appear- 
ance of  nervous  svmptoms,  the  more  unfiivorable  the  prognosis. 

One  should  be  particularly  guarded  in  one's  prognosis  when  stupor 
and  coma  manifest  themselves  early.  Such  cases  are  usually  graver 
than  cases  in  which  the  mind  is  less  markedly  affected,  even  than  those 
in  which  there  is  violent  deliriiun  in  the  evening  and  during  the  night. 

Complete  insomnia  manifesting  itself  during  the  first  days  of  the 
disease  was  justly  considered  a  very  suspicious  symptom  by  the  older 


PROGNOSIS  AND  MORTALITY.  591 

authors.  It  is  not  infrequently  a  precursor  to  the  hopeless  jnunif'estu- 
tion  of  the  disease  that  has  been  aptly  designated  coma-vigil. 

Many  physicians  regard  the  occurrence  of  subsultus  tendinum, 
carphology,  and  choreic  twitchings  and  tremors  as  among  the  most 
dangerous  signs,  and  it  is  certainly  true  that  they  occur  only  in  very 
severe  cases.  These  symptoms  do  not,  however,  affect  the  prognosis  to 
the  same  extent  as  they  do  in  typhoid  fever.  Owing  to  the  self-limited 
and  relati\'ely  short  duration  of  typhus  fever,  the  patient  is  able  to 
withstand,  until  the  occurrence  of  the  crisis,  morbid  conditions  that,  if 
they  were  to  continue  longer,  would  certainly  kill  him. 

General  conviilsions  are  of  unfavorable  omen.  The  great  majority 
of  adults  attacked  by  convulsions  die ;  whereas  children,  who,  as  is  well 
known,  are  attacked  by  convulsions  in  a  large  number  of  much  less 
grave  conditions,  are  more  likely  to  recover. 

Although  we  are  still  in  the  dark  in  regard  to  the  causes  of  many 
changes  in  the  pupil  in  typhus  fever,  we  know  from  clinical  experience 
that  a  few  of  them  are  of  undoubted  value  in  prognosis.  In  severe 
cases  during  the  height  of  the  disease  and,  what  is  even  worse,  during 
the  first  week,  a  very  sluggish  reaction  to  light  is  often  observed.  If 
this  is  accompanied  by  a  high  degree  of  myosis  producing  a  "pin-point" 
pupil,  the  combination  is  of  the  worst  significance.  This  phenomenon, 
designated  by  Graves  and  the  older  English  authors  as  "pin-hole 
pupil,"  I  have  observed  most  often  in  cases  that  ended  in  coma- 
vigil. 

The  condition  of  the  respiratory  organs  deserves  some  attention  in 
determining  the  prognosis.  Reference  has  already  been  made  to  the 
severe  consequences  that  may  be  expected  to  follow  any  marked  involve- 
ment of  the  larynx  for  either  the  future  health  or  the  life  of  the  patient. 

The  significance  of  catarrhal  and  pulmonary  affections  varies  widely 
and  depends  chiefly  on  the  age  of  the  patient.  Whereas  children  and 
young  healthy  adults  under  twenty-five  years  of  age  usually  bear  an 
extensive  attack  of  bronchitis  or  pneumonia  fairly  well,  these  compli- 
cations seriously  threaten  the  life  of  older  persons. 

It  is  not  too  much  to  say  that  after  the  age  of  forty  most  of  the 
deaths  are  directly  or  indirectly  attributable  to  extensive  bronchitis  with 
lobular  pneumonia,  to  hypostases,  or  to  the  frequent  complication  of 
lobar  pneumonia. 

The  condition  of  the  digestive  organs  is  of  subordinate  importance, 
both  from  a  clinical  and  prognostic  point  of  view.  Diarrhea  is  rare, 
but  I  have  met  with  it  both  in  mild  and  in  severe  cases.  Complica- 
tions with   dysenteric   phenomena,   which   have    rarely  been    observed 


592  TYPHUS  FEVER. 

during  the  most  recent  epidemics,  were  justly  regarded  us  grave  acci- 
dents bv  the  okler  authors  (BaralHer,  Peacock,  and  others). 

INIy  experience  leads  me  to  regard  severe  meteorism,  which  is  fortu- 
nately a  rare  occurrence  and  is  luidoubtedly  the  result  of  a  severe  intox- 
iciition  of  the  nerves  supplying  the  muscular  walls  of  the  intestines,  as 
of  the  worst  prognostic  signilicance. 

The  condition  of  the  urine,  both  physicid  and  chemical,  affords  the 
physician  many  valuable  hints.  A  marked  diminution  in  tiie  amount 
of  urine,  or  complete  anuria  lasting  many  days,  indicates  a  degree 
of  cardiac  wciikness  that  eventually  proves  fatal  to  many  patients — to 
the  older  ones  almost  without  exception.  A  careful  determination  of  the 
amount  of  albumin  in  the  urine  is  not  without  its  importance  for  the 
prognosis.  The  early  appearance  of  considerable  amounts  of  albumin  is 
observed  only  in  severe  cases.  If,  in  addition,  there  is  hejuatui-ia,  M'ith 
the  microscopic  findings  characteristic  of  nephritis,  one  has  to  deal  with 
a  very  grave  complication.  Among  all  cases  in  persons  between  thirty 
and  forty  years  of  age  with  nephritis  the  majority  die  ;  among  patients 
of  more  advanced  age  recovery  is  distinctly  exceptional.  It  seems  to 
me  rather  significant  in  this  connection  that  in  all  my  fatal  cases,  except- 
ing a  few  in  which  deiith  was  due  to  special  accidents,  the  urine  persist- 
entlv  showed  a  large  amount  of  albumin. 

Much  prognostic  importance  has  been  attributed  by  many  authors  to 
the  condition  of  the  skin,  by  the  older  writers  partly  because  they  were 
still  under  the  influence  of  the  humoral  theories  of  disease.  Personally, 
I  believe  that  the  importance  of  the  cutaneous  manifestations  has  been 
greatly  exaggerated.  I  cannot  bi'ing  myself  to  agree  with  those  who 
believe  that  the  abundance  of  the  roseolous  rash  is  proportional  to 
the  severity  of  the  case.  It  cannot  be  denied  that  a  pale,  scanty, 
rapidly  disappearing  rash  is  found  more  frequently  in  mild  cases ;  but 
in  any  epidemic  examples  are  found  of  very  severe  and  fatal  cases  in 
which  the  typical  roseolous  rash  was  slow  to  apj^ear  and  developed 
imperfectly  or  even  remained  altogether  absent.  When  it  is  remem- 
bered, moreover,  that  many  of  the  abortive  cases  with  severe  onset 
often  present  from  the  beginning  a  well-marked  and  extensive  rash,  I 
think  it  will  be  admitted  that  the  eruption  in  itself  is  of  little  value  in 
determining  the  prognosis. 

The  hemorrhagic  phenomena,  on  the  other  hand,  are  of  much  more 
serious  import.  Early  and  extensive  hemorrhagic  transformation  of  the 
rose-spots,  and  particularly  the  occurrence  of  petechiae  and  extensive 
hemorrhages  under  the  skin  and  in  the  subcutaneous  cellular  tissue,  as 
has  already  been  stated,  is  always  a  grave  sign.     Cases  that  present  in 


PROGNOSIS  AND  MORTALITY.  '  593 

addition  gangrene  of  the  skin,  tip  of  the  nose,  eai-.s,  fingers,  and  toes  are 
almost  certain  to  end  fatally. 

In  connection  with  the  typhus  fever  rasli  and  its  secondary  altera- 
tions, mention  must  be  made  of  the  diffuse  cyanosis  of  the  face  and 
hands  that,  inasmuch  as  it  indicates  cardiac  weakness,  is  a  particu- 
larly bad  sign.  I  have  rarely  seen  a  patient  with  this  symptom 
recover.  A  few  who  at  first  promised  to  get  well  eventually  died 
of  some  grave  complication. 

Among  the  many  systemic  and  organic  diseases  so  far  referred  to 
that  may  shorten  the  life  of  the  patient,  there  are  some  that  may  be 
regarded  as  localizations  of  the  disease,  while  others  are  complications  in 
the  strict  sense  of  the  word.  It  is,  of  course,  impossible  to  draw  a 
sharp  line  of  demarcation  between  the  two  groups.  It  is  not  too  much 
to  say,  however,  that  the  true  complications  exert  a  special  influence  on 
the  prognosis,  inasmuch  as  they  claim  many  victims  after  the  primary 
disease  has  been  successfully  overcome.  In  this  connection  let  me 
remind  the  reader  of  the  grave  sequels  in  the  region  of  the  pharynx 
and  larynx,  abscess  of  the  lung,  purulent  and  necrotic  pleurisy, 
nephritis,  phlegmon  of  the  skin,  and  malignant  forms  of  decubitus. 
Guttstadt's  repeatedly  quoted  statistics  from  the  Prussian  hospitals  show 
that  in  one-sixth  of  796  fatal  cases  death  occurred  after  the  fifteenth 
day  of  the  disease,  and  in  half  of  these  death  occurred  even  after  the 
thirtieth  day. 

In  the  foregoing  pages  the  prospect  of  recovery  from  typhus  fever 
has  been  shown  to  be  in  general  quite  gloomy,  and  the  many  dangers 
threatening  the  life  of  the  patient  m  all  the  stages  of  the  disease  have 
been  enumerated  ;  in  conclusion,  we  may  add  a  somewhat  more  cheering 
observation. 

Typhus  fever,  like  pneumonia  and  a  few  other  acute  infections, 
belongs  to  the  diseases  characterized  by  a  relatively  short  duration, 
the  morbid  process  ending  by  crisis,  the  extreme  date  of  Avhich  can 
almost  always  be  determined  beforehand.  In  the  very  worst  and 
apparently  desperate  cases  one  may  still  continue  to  hope  for  the  crisis 
and  ultimate  recovery,  and  the  latter  can  often  be  directly  attributed  to 
careful  nursing  and  skilful  handling  of  the  patient  during  collapse.  The 
regular  self-limited  course  of  the  disease  partly  offsets  its  severity  and 
its  danger. 

38 


DIAGNOSIS. 

General  Considerations. — Whenever  it  is  possible  to  observe  a 
well-marked,  typiciil  ease  of  typhus  fever  throughout  or  during  the 
greater  part  of  the  course,  the  diagnosis  presents  very  few  difficulties. 
Even  at  the  beginning  of  the  disease,  or  after  a  few  days'  observation 
during  the  later  stages,  without  any  knowledge  of  the  previous  history, 
it  is  often  quite  easy  to  recognize  the  disease  if  an  epidemic  exists,  and 
if  it  is  found  that  the  patient  has  been  in  close  relations  with  patients 
imdoubtedly  suffering  from  typhus  fever,  or  if  he  has  been  in  their 
houses  or  used  the  same  utensils. 

If,  however,  we  have  to  deal  with  an  isolated  case,  whicli  is  perhaps 
the  first  that  has  occurred  in  the  district,  or  if  tlie  disease  presents 
unusual  phenomena  and  the  course  is  irregular,  the  diagnosis  may  be 
more  difficult. 

In  the  former  case  one  or  two  examinations  will  rarely  enable  the 
physician  to  arrive  at  a  definite  opinion,  and  if  the  case  has  been  under 
observation  some  time,  he  will  realize  the  fact  that  typhus  fever  does  not 
present  any  pathognomonic  train  of  symptoms,  but  that  the  mode  of 
onset  and  subsidence  of  the  various  symptoms,  as  well  as  their  coex- 
istence and  duration,  have  important  parts  in  the  production  of  the 
characteristic  clinical   picture. 

Even  during  an  epidemic  unusual  manifestations  of  the  disease  may 
cause  great  diagnostic  difficulty,  or  even  make  it  quite  impossible  to 
recognize  the  disease. 

Enough  has  been  said  about  the  marked  infectiousness  of  the  disease 
and  tlie  universal  predisposition  found  at  all  ages  and  under  the  greatest 
variety  of  external  cii'cumstances  to  show  the  importance  of  making  a 
clinictd  diagnosis  as  soon  as  jjossible,  not  only  for  the  patient  himself, 
])ut  to  a  much  greater  degree  for  those  surrounding  him  and  for  the 
entire  ])<)pulation  of  the  town  or  district. 

Even  the  morbid  anatomy,  which  in  many  infectious  diseases  affords 
the  means  of  deciding  a  doubtful  case,  is  not  in  itself  sufficient  to  clear 
u]>  the  diagnosis  in  a  doubtful  case.  It  has  been  shown  that  no  distinct 
alterations  j^eculiar  to  the  disease  are  found  in  the  cadaver,  and  the 
autopsy  in  itself  rarely  reveals  more  information  than  that  death  has 
occurred  as  the  result  of  some  acute  infectious  disease. 

594 


DLiGNOSIS.  595 

The  attempt  to  demonstrate  a  patlio<^enic  micro-organism  ^\■llici^ 
should  enable  one  to  diagnose  the  disease  has  so  far  failed  on  account  of 
insurmountable  difficulties.  From  what  has  been  said  about  the  present 
state  of  the  question  it  will  be  seen  that  we  are  still  without  any  knowl- 
edge of  the  most  essential  data.  It  is  probable  that  for  some  time  we 
shall  have  to  depend  on  clinical  observation  alone,  and  the  question 
naturally  presents  itself  whether  there  are  any  reliable  data  on  whicli  to 
base  a  diagnosis  during  the  initial  stage  of  typhus  fever.  The  objective 
symptoms  alone,  without  any  knowledge  of  the  existence  of  an  epidemic 
or  other  possibilities  of  infection,  enable  one  at  best  to  make  only  a 
provisional  diagnosis.  In  most  cases  it  is  impossible  to  say  more  than 
that  some  acute  infectious  disease  is  impending. 

The  most  important  diseases  in  the  differential  diagnosis  are  the  acute 
exanthemata,  especially  small-pox  and  scarlet  fever,  relapsing  fever, 
cerebrospinal  meningitis,  and  cryptogenic  septicopyemia — much  more 
rarely  typhoid  fever. 

Differ ential  Diagnosis  in  Initial  Stage. — The  initial  stage 
of  typhus  fever  presents  many  points  of  resemblance  to  that  of  small- 
pox :  the  same  sudden  onset  with  chills,  a  rapidly  rising  pyrexia  with* 
out  or  with  relatively  slight  remissions,  early,  profound  prostration, 
severe  pain  in  the  head  and  limbs,  and  splenic  enlargement,  which 
usually  can  be  demonstrated  at  the  beginning  of  the  first  week  of  the 
disease. 

The  fact  that  pain  in  the  back  is  a  much  more  frequent  and  violent 
symptom  in  the  initial  stage  of  variola  than  in  that  of  typhus  fever  is  of 
slight  diagnostic  significance,  for  the  symptom  in  itself  is  rather  vague 
and  is  not  rarely  absent  in  the  milder  forms  of  small-pox.  On  the 
other  hand,  the  early  appearance  of  an  initial  scarlatinal  rash  ^  on  the 
thigh  and  upper  arm  is  of  some  importance  and  strongly  points  to 
small-pox,  as  it  is  particularly  likely  to  occur  in  the  severe  forms  of 
that  disease  and  does  not  occur  either  in  typhus  fever  or  in  any  other  of 
the  acute  infectious  diseases.  On  the  other  hand,  an  initial  measlv  rash 
is  of  secondary  importance.  Very  similar  and  rapidly  disappearing 
rashes  occur,  as  we  have  seen,  shortly  before  or  with  the  first  appear- 
ance of  the  specific  typhus  fever  rose-spots ;  but  the  diagnosis  is  soon 
cleared  up  by  the  appearance  of  the  latter  or  by  the  eruption  of  typical 
small-pox  lesions,  the  nature  and  distribution  of  which  are  characteristic 
even  during  the  initial  stage. 

Finally,  it  may  be  well  to  point  out  how  slightly  the  face  is  involved 

^  Compare  Cursclimann,  "Die  Pocken,"  von  Ziemssen's  Handh.,  Bd.  i.,  second 
edition. 


596  TYPHUS  FEVER. 

iu  comparison  with  other  parts  of  the  boily  in  typhus  lever,  in  contra- 
distinction to  small-pox,  iu  which  the  characteristic  rash  appears  early 
and  is  very  abundant  on  the  face. 

The  temperature  in  both  diseases  at  the  end  of  the  initial  stage  and 
at  the  beginning-  of  the  eruption  is  of  some  im])ortanee.  While  in 
typhus  the  fever  is  high  during  this  lime  and  nut  rarely  continues  to 
rise,  there  is  always  a  marked  fall  in  temperature  in  vai'iola  down  to 
and  even  below  the  normal  in  ordinary  cases. 

The  diagnosis  may  be  well-nigh  impossible  when  there  is  a  question 
between  the  fulminating  hemorrhagic  form  of  typhus  fever  and  the 
analogous  form  of  small-pox — so-called  purpura  variidosa.  Both  rep- 
resent a  hemorrhagic  initial  stage  of  the  disease  and  end  fatally  before 
the  typical  symptoms,  especially  the  rash,  become  fully  developed.  Even 
after  an  autopsy  has  been  held  it  may  not  be  possible  to  arrive  at  a 
deiinite  conclusion,  and  the  diagnosis  may  have  to  be  decided  by  the 
prevalence  of  one  or  the  other  of  the  two  diseases  in  the  district  and 
the  possibility  of  the  patient  having  become  infected.  Similar  diffi- 
culties are  encountered  in  the  differential  diagnosis  from  severe  hemor- 
rhagic forms  of  other  acute  infectious  diseases.  I  need  refer  only  to  the 
corresponding  forms  of  scarlet  fever  and  even  of*  typhoid  fever. 

The  differential  diagnosis  from  relapsing"  fever  during  the  first, 
or  even  the  second,  attack,  if  the  first  has  not  been  sufficiently  Avell 
observed,  is  extremely  difficult,  especially  if  one  remembers  that  the  dis- 
ease often  coexists  with  typhus  fever,  as  was  the  case  in  Berlin  in  1879. 
In  many  cases  there  is  nothing  characteristic  about  the  mode  of  onset, 
rise,  and  ultimate  height  of  the  fever.  The  appearance  and  general 
condition  of  the  patient  are  of  much  more  importance  in  the  diagnosis 
of  relapsing  fever.  As  a  rule,  the  general  condition  is  remarkably  good 
in  comparison  to  the  height  of  the  fever,  there  is  little  involvement 
of  the  sensorium,  and  the  only  symptom  complained  of  is  a  painful 
tugging  sensation  in  the  calf  of  the  leg.  Although  these  points  are 
more  or  less  in  favor  of  relapsing  fever,  nevertheless  it  cannot  be  said 
that  more  severe  initial  symptoms,  snch  as  violent  headache  and  pain  in 
the  limbs,  with  profound  prostration  and  even  petechia  (I  need  only 
remind  the  reader  of  the  well-known  "flea-bite  rash"),  absolutely 
exclude  the  existence  of  relapsing  fever. 

Many  relapsing  fever  patients  present,  at  the  very  beginning  of  the 
disease,  a  peculiar  color  of  the  skin,  a  point  that  we  frequently  utilized 
with  remarkable  success  during  the  epidemic  in  Berlin,  and  that  decided 
the  admittance  and  assignment  of  the  patients  to  the  various  wards.  It 
is  a  peculiar,  dull,  yellowish-gray  discoloration,  Avhich  may  best  be  com- 


DIAGNOSIS.  597 

pared  to  tlic  color  of  anemic  individuals  who  have  been  for  some  time 
exposed  to  the  sun. 

As  regards  the  spleen,  I  cannot  agree  with  authors  who  affirm 
that  it  presents  any  characteristic  enlargement  during  the  initial  stage 
of  either  disease. 

*  The  diagnosis  of  relapsing  fever,  however,  can  always  be  established 
by  the  finding  of  spirilla  in  the  blood,  and  these  organisms  are  usu- 
ally demonstrable  shortly  before  or  after  the  first  and  every  succeeding 
attack. 

During  their  subsequent  course  the  two  diseases  present  such  marked 
differences  that  the  diagnosis  cannot,  except  under  very  special  circum- 
stances, remain  in  doubt  for  any  length  of  time. 

Of  course,  the  diagnosis  may  present  peculiar  difficulties  when  a 
convalescent  from  relapsing  fever  is  immediately  attacked  by  typhus 
fever.  Reference  has  been  made  to  this  comparatively  frequent  possi- 
bility (see  Fig.  57).  It  need  hardly  be  emphasized  that  the  absence  of 
spirilla  during  the  beginning  of  the  fever,  and  the  appearance  of  rose- 
spots  a  few  days  later,  suffice  to  remove  any  doubts  that  may  exist. 

Relapsing  fever  leads  us  naturally  to  the  discussion  of  malarial 
fever.  It  will  readily  be  seen  that  first  attacks  of  this  disease  in 
countries  where  it,  as  well  as  typhus,  is  endemic  may  easily  lead  to 
error.  Difficulties  may  especially  be  encountered  in  severe  forms  of 
malaria  with  early  involvement  of  the  sensorium  and  great  prostration, 
such  as  occur  in  the  tropics  and  also  in  Holland,  Hungary,  and  Italy. 
As  in  relapsing  fever,  the  examination  of  the  blood  and  the  finding  of 
the  Plasmodium  will  at  once  clear  up  the  diagnosis  without  the  neces- 
sity of  waiting  for  the  characteristic  fall  in  temperature. 

It  may  be  exceedingly  difficult,  especially  when  an  epidemic  of 
typhus  fever  exists,  to  distinguish  isolated  cases  of  cryptogenic 
septicopyemia  in  its  early  stages  from  the  initial  or  eruptive  stage 
of  typhus  fever.  An  initial  chill  and  a  rapid  rise  of  the  temperature  to 
a  considerable  height,  early  marked  involvement  of  the  whole  system, 
especially  affecting  the  nerves,  are  common  to  both  diseases,  and  the 
difficulty  may  be  further  increased,  particularly  at  the  beginning,  by 
the  mode  of  appearance  and  distribution  of  the  cutaneous  rash. 

I  recently  saw  an  interesting  case  of  this  kind.  A  young  man  who  had 
recently  come  from  Silesia  was  seized  with  violent  chills,  headache,  retching 
and  vomiting,  and  was  admitted  to  ray  clinic  with  a  high  fever  and  marked 
splenic  enlargement.  There  was  great  disturbance  of  consciousness.  The 
fever-curve  at  first  presented  the  character  of  a  high  continuous  remittent 
fever.  Between  the  third  and  fourth  days,  after  a  slight  transitory  morbil- 
liform rash  on  the  arms  and  thighs  had  appeared,  an  ill-defined,  livid,  small 


598  TYPHUS  FEVER. 

UKK'iihir  rash  nitide  it;?  appearauce,  which  soon  became  petechial  in  character 
aud  presented  a  suspicious  ilistril)ution,  being  more  abundant  on  the  hands 
and  feet,  especially  tiie  backs  of  the  feet,  and  much  less  marked  on  the  trunk. 
As  a  precautionary  measure  the  patient  was  isolated  for  a  few  days. 

The  rash  continued  to  appear  in  successive  crops,  the  patient  had  several 
chills,  and  a  few  hemorrhagic  spots  appeared  on  the  soles  of  the  feet,  the 
palmar  surfaces  of  the  lingers,  the  plantar  surfaces  of  the  toes,  and  under  the 
nails.  On  the  sixth  day  of  the  disease  the  sudden  appearance  of  a  loud, 
blowing  endocarditic  murmur  conlinned  the  diagnosis  of  sei)ticopyemia  with 
nntral  verrucose  endocarditis,  which  diagnosis  had  already  been  made  on 
the  strength  of  the  changes  in  the  eruption  and  the  appearance  of  chills. 
The  diagnosis  was  contirmed  at  the  autopsy,  which,  however,  failed  to  reveal 
the  original  cause  of  the  condition. 

The  clinical  picture  in  a  typical  case  of  cerebrospinal  menin- 
gitis would  .seem  to  differ  sufficiently  from  that  of  tyj)hus  fever  to 
preclude  all  danger  of  error,  but  it  is  true,  nevertheless,  that  irregular 
cases,  in  the  initial  stages  of  the  two  diseases,  often  present  considerable 
difficulties.  It  cannot  be  denied  that  there  are  cases  of  cerebrospinal 
menmgitis  that  begin  ^^ith  a  chill  and,  after  a  rapid  rise  of  temperature, 
soon  lead  to  disturbances  of  consciousness  or  even  to  coma.  If  we 
remember  also  the  violent  headache  from  which  the  patients  suffer,  the 
pain  in  the  back,  which  does  not  by  any  means  always  manifest  itself 
in  the  form  of  a  characteristic  rigidity  of  the  neck,  and  the  occasional 
appearance  of  a  roseolous  rash  during  the  very  first  days — even  before 
the  rigidity  of  the  neck — ^we  have  sufficient  explanation  for  occasional 
errors  in  diagnosis. 

Diagnosis  in  the  Stage  of  Eruption. — Even  after  the  end  of 
the  initial  stage  and  after  the  typhus  fever  rash  has  made  its  appearance 
and  begun  to  spread,  the  differential  diagnosis  may  present  some  diffi- 
culties. There  is  a  lamentable  want  of  unanimity  in  the  opinions  of 
many  physicians  and  even  in  the  better  text-books  m  regard  to  the 
form,  distribution,  and  development  of  the  eruption.  It  should  be  dis- 
tmctly  remembered  that  the  specific  rose-spots  are  always,  at  least  in 
the  begmning,  purely  hyperemic,  often  very  pale  and  indistinct,  and 
that  only  a  portion  of  them  later  become  more  or  less  markedly  hemor- 
rhagic. There  is  a  wide-spread  erroneous  belief,  and  one  that  has  been 
perpetuated  in  the  vicious  name  of  "petechial  tyj^hus,"  that  the  eruption 
of  typhus  fever  from  the  very  outset  takes  the  form  of  small  hemor- 
rhages. On  the  contrary,  it  may  be  stated  definitely  that  any  febrile 
case  in  which  the  cutaneous  changes  at  once  appear  in  the  form  of 
larger  or  smaller  hemorrhages,  without  any  prodromal  stage,  is  not 
typhus  fever. 

Diagnostic  Significance  of  the  Eruption. — Another  point 


DIAGNOSIS.  599 

of  general  importance  may  be  meDtioned.  It  is  the  great  variability 
of  the  eruption  as  regards  its  abnndance  and  distribution.  From  the 
rare  cases  with  abundant  eru})ti()n  covering  the  trunk  and  extremities, 
we  have  every  possible  gradation,  down  to  those  cases  in  which,  from  the 
very  beginning  of  the  disease  and  throughout  its  entire  duration,  it  is  prac- 
tically impossible  to  demonstrate  any  characteristic  changes  in  the  skin. 
Even  cases  of  so-called  "febrls  exanthematica  nine  exanthemute  "  although 
rare,  cannot  be  entirely  excluded.  It  is  owing  to  this  want  of  uni- 
formity in  the  eruption,  both  as  regards  its  general  appearance  during 
different  epidemics  and  also  in  individual  patients  during  the  same  epi- 
demic, that  the  diagnosis  from  other  infectious  diseases  characterized 
by  high  fever  without,  or  at  best  with  very  slight,  changes  in  the  skin, 
may  be  exceedingly  difficult. 

Difficulties  of  this  kind  present  themselves  especially  when  it  is 
necessary  to  decide  between  typhus  and  typhoid  fever,  the  disease 
which,  in  all  its  stages  and  in  all  features,  stands  in  closest  diagnostic 
relationship  to  it  and  which  undoubtedly  presents  the  greatest  difficulties 
in  differential  diagnosis. 

Typhus  and  Typhoid  Roseolse. — In  regard  to  the  roseolous 
eruption,  which  is  so  often  considered  diagnostic,  it  may  be  equally 
abundant  or  equally  scanty  in  both  diseases.  It  has  already  been 
pointed  out  that  cases  of  typhus  fever,  however  severe  from  the  very 
beginning,  may  present  only  a  few  roseolse  scattered  exactly  as  in  typhoid 
fever,  and,  conversely,  typhoid  fever  may  be  combined  with  a  rash  that 
even  in  typhus  fever  would  have  to  be  regarded  as  abundant.  Since, 
then,  the  number  of  the  rose-spots  cannot  be  depended  upon,  it  is  all 
the  more  important  to  make  a  careful  study  of  their  mode  of  devel- 
opment, distribution,  and  individual  characteristics.  In  regard  to  the 
development,  it  is  to  be  noted  that  the  rash  of  typhus  fever  appears 
very  much  earlier  than  that  of  typhoid  fever — between  the  second 
and  fifth  days  of  the  disease — that  the  lesions  continue  to  appear  in 
unbroken  succession  instead  of  in  successive  crops,  and  reach  their  ulti- 
mate number  and  development  within  a  few  days. 

The  distribution  of  the  rose-spots  over  the  surface  of  the  body  is 
next  in  importance.  Whereas  in  typhoid  fever  the  trunk  is  most  thickly 
covered  and  the  extremities  escape  altogether,  or  the  spots  become  less 
and  less  numerous  the  greater  the  distance  of  the  parts  from  the  trunk, 
the  eruption  in  typhus  fever  is  fairly  uniform  and  covers  both  the  trunk 
and  the  extremities. 

Rose-spots  on  the  forearms  and  legs  and  on  the  hands  and  feet  are 
extremely  rare  in  typhoid  fever,  whereas  involvement  of  the  backs  of 


600  TYPHUS  FEVER. 

the  hands  and  feet  is  extremely  common,  not  to  say  typical,  in  typhus 
fever,  so  that  I  always  subject  these  places  to  a  careful  examination  in 
any  suspicious  case. 

Although  the  appearance  of  the  face  in  the  two  diseases  is  to  a  ceitain 
extent  similar  in  so  far  as  it  never  becomes  the  seat  ol  rose-spots  in 
typhoid,  and  very  rarely  in  typhus  fever,  yet  there  is  a  marked  contrast 
between  the  intensely  swollen,  reddened  facies,  with  deeply  injected  or 
even  hemorrhagic  conjunctivte  and  wild  look  of  a  typhus  fever  patient, 
and  the  pallid,  stuporous,  and  prostrated  appearance  in  typhoid  fever. 

The  individual  lesions  present  veiy  considerable  and  distinct  differ- 
ences in  the  two  diseases.  AVhereas  the  rose-spots  of  typhoid  fever 
are  from  the  beginning  elevated,  papular,  with  sharp,  circular  out- 
lines, and  retain  their  purely  hyperemic  character  throughout,  the  erup- 
tion of  t^^hus  fever  at  first  appears  in  the  form  of  pale,  indistinct, 
hyperemic  patches,  with  irregular,  ill-defined  borders,  which  gradually 
become  darker  and  eventually  somewhat  hemorrhagic  (compare  Plates  1 
and  2).  Hence  the  non-papular  character  of  the  eruption  during  and 
after  the  height  of  its  development  is  an  important  diagnostic  feature. 
The  spots  are  pale,  and  only  during  the  first  few  hours  are  they  slightly 
elevated — never  so  distinctly  papular  as  in  typhoid  fever. 

OTHER  DIFFERENTIAL  SIGNS   BETWEEN  TYPHUS  AND  TYPHOID. 

Secondj^nly  in  importance  to  the  condition  of  the  skin  is  the  fever 
in  the  differential  diagnosis  between  the  two  diseases.  In  contradistinc- 
tion to  the  sloAv,  step-like  ascent  of  the  curve  in  typhoid  fever,  we  have 
seen  that  in  typhus  fever,  after  an  initial  chill,  the  temperature  rapidly — 
withm  from  tsventy-four  to  fortry^-eight  hours — and  with  much  smaller 
morning  remissions,  rises  to  a  height  rarely  reached  in  the  former  dis- 
ease. Temperatures  of  40.5°  C.  or  even  41°  are,  as  we  have  seen,  quite 
common  at  this  stage,  and  may  persist  and  even  continue  to  increase 
with  relatively  slight  morning  remissions  until  the  end  of  the  first  week. 
The  character  of  the  temperature-cur%^e  during  the  first  week  positively 
distiuguishes  typhus  from  typhoid  fever.  As  even  the  most  severe  cases 
of  typhus  fever  rarely  last  more  than  from  fourteen  to  seventeen,  or  at  most 
twenty,  days  before  defei'^'escence  begins,  and  the  fever  falls  by  crisis  or 
at  least  by  a  succession  of  rapid  declines,  we  ai-e  not  without  important 
differential  signs,  even  during  the  latter  period  of  the  disease. 

In  accordance  with  the  rapid  rise  and  great  intensity  of  the  fever 
during  the  first  days  of  the  disease  the  disturbances  of  the  patient's  gen- 
eral condition  arc  much  more  severe  and  manifest  themselves  much  earlier 
than  in  typhoid  fever. 


DIAGNOSIS.  601 

Whereas  a  typhoid  fever  patient  not  infrequently  remains  at  work 
or  at  least  does  not  go  to  bed  during  the  first  week  of  the  disease,  the 
prostration  in  typhus  is  so  great  from  the  very  l)eginning  that  the 
patients  are  forced  to  take  to  their  beds  on  the  first  or  the  second  day. 
Delirium,  stupor,  and  coma  declare  themselves  during  the  first  week  in 
typhus  fever,  but  their  appearance  is  delayed  much  longer  in  tyjihoid, 
or,  if  they  do  exceptionally  occur  early,  they  are  due  to  some  cerebral 
complication. 

In  many  respects  the  pulse  in  typhus  differs  considerably  from  that 
usually  observed  in  typhoid  fever.  The  relatively  low  rate  characteristic 
of  the  latter  disease  in  youthful  individuals,  especially  of  the  male  sex, 
is  not  observed  in  typhus  fever.  In  both  sexes  and  in  all  ages  the  pulse 
is  comparatively  rapid  from  the  very  beginning — 110  and  more  in  the 
evening  is  not  unusual  even  during  the  first  week  in  vigorous  men. 
The  characteristic  dicrotism  seen  in  typhoid  is  only  exceptionally 
observed  in  typhus  fever. 

Enlargement  of  the  spleen  is  a  more  regular  and  lasting  phenomenon 
in  typhoid  than  in  typhus  fever.  The  time  of  its  appearance  also  differs 
in  the  two  diseases.  In  typhus  fever,  if  it  is  present  at  all,  it  appears 
early  and  disappears  at  a  time  when  it  would  still  be  present  in  typhoid 
fever. 

The  abdominal  symptoms  are  of  very  little  importance  as  diagnostic 
signs  between  the  two  diseases.  Thus  a  moderate  degree  of  meteorism 
quite  commonly  develops  in  severe  cases  of  typhus,  while,  on  the  other 
hand,  it  may  be  absent  during  the  entire  duration  of  a  typhoid  fever 
attack  and  usually  is  so  during  the  early  stages.  Diarrhea^  is  not  by 
any  means  so  constant  in  typhoid  fever  as  is  usually  supposed,  while 
in  typhus  thin  stools  of  a  pale  yellow  color  are  not  at  all  uncommon. 

Some  of  the  newer  methods  of  examination  will,  no  doubt,  prove  of 
the  greatest  value  in  future  epidemics  and  will  help  to  decide  the  diag- 
nosis in  many  a  doubtful  case. 

The  demonstration  of  typhoid  bacilli  in  the  blood,  urme,  rose-spots, 
and  feces,  and  the  behavior  of  cultures  of  this  baciUus  when  added  to 
the  blood-serum  of  the  individual  are  the  most  important  of  these 
methods. 

The  Gruber-Widal  agglutination  test  will  enable  us  in  many  cases  to 
differentiate  the  two  diseases,  although,  it  is  true,  only  at  a  somewhat 
later  stage. 

Whether  the  absence  of  leukocytosis  or  hypoleukocytosis  observed 
in  typhoid  fever  will  distinguish  this  from  typhus,  as  it  does  from  some 

1  Compare  the  chapter  on  this  subject  in  the  author's  work  on  typhoid  fever. 


602  TYPHUS  FEVER. 

of  the  other  acute  infectious  diseases,  such  as  pneumonia  and  septic  con- 
ditions, which,  as  m'c  all  know,  regularly  show  a  marked  leukocytosis, 
has  not  yet  been  definitely  decided.  Conibcnialc  speaks  of  a  moderate 
increase  in  the  number  of  white  blood-cells  in  the  blood  of  typhus  fever 
patients.  Four  cases  recently  treiited  in  the  Johns  Hopkins  Hospital 
showed  a  moderate  degree  of  leukocytosis. 

The  diazo-reaction  is  probably  not  of  any  diagnostic  value.  Several 
authors  (Eichhorst,  Vierordt)  have  frequently  found  it  to  be  positive  in 
typhus  fever. 

While  the  differential  diagnosis  from  small-pox,  as  we  have  seen, 
presents  great  difficulties,  especially  during  the  initial  stage,  other  acute 
exanthemata,  particularly  measles,  may,  during  the  period  of  eruption, 
prove  equally  confusing.  The  eruption  of  measles,  especially  during 
the  first  few  hours  after  its  appearance,  may  closely  resemble  that  of 
typhus  fever,  and,  conversely,  the  rash  of  typhus  fever  before  the 
beginning  of  hemorrhagic  transformation,  when  it  is  abundant  and 
confluent  in  places,  and  accompanied  by  the  macular  rash  that  has 
been  described,  may  easily  be  confounded  with  the  eruption  of  measles. 

As  a  rule,  the  diagnosis  can  be  made  by  a  careful  examination  of  the 
remainder  of  the  skin.  It  is  to  be  remembered  that  the  face  is  first 
attacked  in  measles,  while  in  typhus  fever  it  escapes  entirely,  or,  in 
rare  cases,  is  the  seat  of  a  few  isolated  rose-spots  which  then  are 
characteristic.  In  any  case  of  typhus  fever,  even  when  the  rash  is 
abundant,  areas  will  be  found  on  the  body  where  it  is  more  sparsely  dis- 
tributed and  where  the  spots  are  distinct  enough  to  make  them  easily 
recoo-nizable. 

The  conversion  of  at  least  a  part  of  the  rose-spots  into  petechiae 
is  of  some  diagnostic  value  for  typhus  fever.  Hemorrhagic  measles  is 
rare  and  need  hardly  be  taken  into  consideration  in  the  differential 
diagnosis. 

The  condition  of  the  mucous  membranes  (conjunctivae,  nasopharynx, 
bronchi)  presents  nothing  distinctive.  Catarrh  of  these  structures 
occurs  in  both  diseases,  and  the  intensity  and  distribution  are  so 
variable  that  it  is  impossible  to  draw^  any  definite  conclusion. 

If  the  patients  are  seen  during  the  beginning  of  the  fever  before  the 
eniption  appears,  or  if  reliable  data  in  regard  to  this  period  can  be 
obtained,  the  decision  becomes  much  easier.  The  rapid  rise  and 
unusual  height  of  the  temperature,  and  its  persistence  or  even  subse- 
quent rise  after  the  appearance  of  the  eruption  and  during  the  entire 
first  week  of  the  disease,  are  never  observed  in  measles. 

Other  diseases  that  are  occasionally  mentioned  in  this  connection  are 


DIAGNOSIS.  603 

of  secondary  importance  in  the  differential  diagnosis.  In  very  rare 
cases  a  central  pneumonia  may  become  a  source  of  error.  Kven 
more  rarely,  and  only  under  special  (conditions,  an  error  might  occur 
in  scarlatina,  certain  infectious  exanthemata,  and  in  severe 
cases  of  purpura. 

Anthrax  and  possibly  glanders  might  for  a  time  give  rise  to 
doubt,  the  former  only  in  the  extremely  rare  cases  of  cerebral  or  intestinal 
anthrax  without  edema  or  furunculosis ;  the  latter,  when  the  character- 
istic manifestations  in  the  mucous  membrane  of  the  nose,  trachea,  and 
bronchi  are  less  marked  and  the  changes  in  the  skin  are  imperfectly 
developed.  In  the  case  of  anthrax  the  question  would  be  decided  at 
once  by  the  bacteriologic  examination,  which  in  glanders  is  often  more 
difficult. 


PROPHYLAXIS. 

Although  we  have  no  exact  knowledge  of  the  nature  and  mode  of 
development  of  the  micro-organism  that  is  the  cause  of  typhus  fever, 
its  effects,  so  far  as  they  relate  to  the  origin  and  spread  of  the  disease, 
are  sufficiently  well  known  to  enable  us  to  adopt  certain  definite  pre- 
cautions which  are  very  efficient,  if  properly  carried  out,  against  the 
transmission  of  the  disease  from  patient  to  patient  and  its  general 
spread. 

The  most  important  points  in  the  prevention  of  the  disease  have 
been  embodied  in  a  few  conclusions  at  the  end  of  the  chapter  on 
Etiology. 

REGULATION  OF  GENERAL  AND  LOCAL  HYGIENIC  CONDITIONS. 

The  precautionary  measures  based  on  these  considerations  may  be 
divided  into  those  that,  by  improving  the  general  and  local  hygienic 
conditions,  deprive  the  disease  of  a  proper  medium  for  its  development, 
and  those  that  are  calculated  to  prevent  the  spread  of  the  disease  from 
one  patient  or  articles  used  by  him  to  other  persons,  or  the  spread  from 
one  town  to  a  neighboring  town  or  to  remote  regions  and  countries. 

INlany  of  the  most  important  prophylactic  principles  were  first  laid 
down  by  the  older  authors,  among  whom  no  one  has  expressed  them  more 
clearly  and  more  une<:pnvocally  than  Hildenbrand.  But  even  he,  like 
Murchison  and  Griessinger,  was  never  quite  able  to  rid  himself  of  the 
idea  that  the  disease  might  arise  spontaneously,  a  theory  that  to-day  has 
been  permanently  refuted. 

However,  to  say,  as  some  authors  have  done,  that  anything  that  does 
not  directly  affect  the  development  and  spread  of  the  specific  contagium 
is  of  no  consequence,  would  be  to  overlook  the  most  important  general 
principles  in  the  prevention  of  the  disease.  We  know  that  hunger  and 
misery,  insufficient  food,  overcrowding  in  badly  ventilated  rooms,  filth, 
and  the  accumulation  of  decomposing  substances  cannot,  it  is  true,  pro- 
duce the  contagium  of  typhus  fever,  but  we  are  more  fully  than  ever 
convinced  that  they  afford  a  most  fiivorable  soil  for  its  development. 
Hence  the  name,  hunger  typhus  ;  hence  the  distmctly  social  nature  of 
this  disease,  which  attacks  the  individual  whenever  his  health  has  been 

604 


PROPHYLAXIS.  605 

undermined  by  hunger  and  vice  and  his  body  lias  been  prepared  for 
the  reception  and  development  of  the  germ. 

The  shortest  way  for  the  state  and  society  in  general  to  deprive  the 
disease  of  its  soil  is  to  improve  the  well-being  and  sanitary  conditions 
of  the  less  favored  classes,  especially  in  regions  and  during  times  when 
there  is  danger  of  the  disease-poison  being  imported. 

In  large  cities,  esjiecially  during  times  of  epidemic,  the  tenements 
of  the  poorer  population,  the  poorer  inns  and  cheap  lodging-houses 
(known  in  Berlin  as  "  Pennen  "),  all  institutions  for  those  who  have  no 
homes,  workhouses,  poorhouses,  and  prisons  should  be  carefully  inspected 
by  the  authorities.  All  ships,  especially  emigrant  ships,  should  also  be 
subjected  to  a  careful  inspection. 

When  war  is  being  waged  in  a  country  in  which  the  disease  is  pre- 
sumably epidemic,  the  greatest  attention  should  be  given  to  a  proper 
housing  of  the  troops,  the  arrangement  of  the  camp,  and  the  feeding 
and  general  care  of  the  soldiers'  bodies. 

How  much  can  be  accomplished  in  this  direction  was  shown  during 
the  Crimean  war,  in  1856,  especially  during  the  siege  of  Sebastopol,  by 
the  different  conditions  of  the  French  and  English  armies,  which  fought 
shoulder  to  shoulder.  Whereas  the  disease  carried  off  but  few  victims 
among  the  English,  whose  hygiene  was  well  looked  after  and  who  were 
rationally  fed,  the  neglect  of  the  simplest  hygienic  measures  avenged 
itself  among  the  French  by  a  decimation  of  their  army  by  the  disease, 
which  claimed  more  victims  than  musket  and  saber. 

During  the  approach  of  an  epidemic  the  passenger  as  well  as 
freigflit  traffic  from  neighboring  countries,  including  all  objects  to 
which  the  poison  could  adhere,  requires  the  most  careful  attention. 
Clothing,  washing,  and  anything  that  is  suspicious  in  this  respect  should 
either  be  excluded  altogether  or  be  subjected  to  a  systematic  disinfection 
before  it  is  allowed  to  pass  the  frontier. 

Passenger  traffic  cannot  nowadays  be  interrupted,  as  it  could  formerly 
in  the  days  of  land  quarantine ;  it  can,  however,  be  kept  under  super- 
vision by  the  sanitary  police.  Attention  should  be  directed  especially 
to  tramps  and  vagabonds  and  their  lodgings,  to  taverns,  asylums, 
prisons,  railroad  stations,  etc.  Every  suspicious  case  of  disease  should, 
if  possible,  be  at  once  isolated  either  on  the  spot  or  in  the  nearest 
suitable  hospital.  Even  the  dwellings  of  healthy  immigrants  from 
infected  regions,  the  streets  and  districts  in  large  cities  where  they  are 
in  the  habit  of  lodging  and  carrying  on  their  business,  ought  to  be  under 
constant  sanitary  supervision,  so  that  any  one  attacked  by  the  disease 
may  at  once  be  sent  to  the  nearest  hospital,  and,  if  possible,  the  other 


606  TYPHUS  FEVER. 

menibei"s    of   the    household,    even    if  healthy,    be   kept  under  careful 
ohservation. 

It  is  a  good  plau,  wheu  an  epidemic  is  approaching,  to  make  a  regular 
evening  examination  of  the  inmates  of  houses  of  refuge  and  lotlging-houses. 
In  1877,  while  I  was  visiting  the  asylums  and  suspicious  loclging-houses 
("Pennen  "  j  in  Berlin,  1  found,  in  one  night,  5  typhus  fever  jiatients  scat- 
tered among  the  liealthy  inmates.  I  immediately  referred  them  to  the 
lazaretto  in  Moahit. 

I  need  ouly  nieution  in  passing  the  desirability  of  a  well-organized 
Bureau  of  Statistics  in  times  of  impending  epidemic,  for  the  purpose  of 
keeping  the  authorities  informed  of  the  state  of  the  disease  and  the 
general  hygienic  conditions  in  neighboring  districts. 

Isolation. — If,  in  sjiite  of  all  precautionary  measures,  the  disease 
obtains  a  foothold  in  a  given  region,  everything  may  depend  on  early 
recognition  of  the  first  cases  and  energetic  measures  directed  to  the  iso- 
lation of  the  patients.  An  epidemic  may  be  confined  within  narrow 
limits,  or  may  even  be  nipped  in  the  bud  if  the  authorities  can  succeed 
in  protecting  the  inunediate  vicinity  of  the  infected  district  and  the 
remaining  population  from  the  disease,  and  so  preventing  new  cases  from 
developing,  or  at  least  in  isolating,  so  soon  as  possible,  those  that  have 
developed. 

In  the  prophylactic  treatment  of  typhus  fever  patients  one  should 
carefully  bear  in  mind  what  we  have  learned  by  experience,  namely, 
that  the  exciting  cause  of  typhus  fever  emanates  exclusively  from  the 
patient  himself,  from  his  immediate  surroundings,  and  from  objects  that 
he  has  used,  and,  given  the  same  predisposition,  the  virulence  of  the 
poison  is  inversely  proportional  to  the  amount  of  space  and  ventilation. 

These  facts  must  be  remembered  in  the  transportation  of 
patients.  Whenever  the  disease  is  prevalent,  public  conveyances 
should  never  be  used  for  the  transportation  of  well-pronounced  or  sus- 
picious cases,  or  even  of  individuals  suffering  from  an  indefinite  fever. 

In  large  cities  there  is,  as  a  rule,  no  lack  of  proper  facilities  for  trans- 
portation in  our  day.  In  smaller  places  an  efficient  service  can  easily  be 
improvised. 

If  the  regular  patrols  designed  for  this  purpose  are  inadequate  in 
large  cities,  none  but  persons  well  acquainted  with  the  special  dangers 
of  the  disease  should  be  intrusted  with  the  transportation  of  patients, 
and  this  sliould  not  be  left  to  police  officials,  prison  wardens,  or  more 
ignorant  persons.  The  drivers  of  such  vehicles  should  not  be  alloAved 
to  drive  any  otlier  conveyance,  and  they,  as  well  as  the  remainder  of 
the  force,  and  even  the  wagons,  should  be  furnished  by  the  hospitals. 


PROPHYLAXIS.  607 

and  these  men  should  also  lodge  in  the  hospital  and  be  placed  under 
sanitary  supervision. 

The  method  of  housing  and  isolating  tlu;  ])ationts,  the  choi(!e  and 
arrangement  of  wards  in  the  hos])itals  or  of  sick-rooms  in  private  houses, 
as  well  as  the  situation  and  internal  arrangements  of  hospitals,  will  be 
discussed  in  the  section  on  Treatment,  together  with  other  general  i)rin- 
ciples  to  be  observed  in  the  care  of  patients.  In  the  same  place  will  be 
given  a  few  necessary  precautions  which  should  be  observed  by  those  in 
immediate  attendance  on  the  patients — physicians,  hospital  attendants, 
and  officials  connected  with  the  institution. 

Immediately  after  admittance  to  the  hospital  the  patients  should 
receive  a  bath  and  be  carefully  cleansed ;  their  clothing  and  underwear 
should  be  properly  disinfected  and  kept  in  large,  well-ventilated  rooms 
at  some  distance  from  the  wards  until  the  patient  is  discharged.  The 
patients  should  be  dressed  in  clothing  provided  by  the  hospital,  and 
should  be  strictly  prohibited  from  using  any  other  garments.  Any  part 
of  the  clothes  or  other  effects  belonging  to  the  patients  that  cannot  be 
easily  disinfected  or  that  is  worn  out,  torn,  or  of  no  value,' should  be 
destroyed  by  fire.  It  is  less  costly  to  pay  the  patients  a  small  indemnity 
for  such  destruction  of  clothing  than  to  run  the  risk  of  infectmg  an  entire 
district  by  the  disregard  of  this  precaution. 

Even  in  smaller  towns,  where  no  time  has  been  given  for  preparation 
when  the  first  cases  are  discovered,  infected  material  can  easily  be  burned 
in  the  open  air  in  some  vacant  field.  If  this  should  not  be  feasible,  the 
offending  objects  can  be  rendered  harmless  by  burying  them  in  the  ground 
at  a  depth  of  from  one  and  a  half  to  two  meters. 

The  most  careful  directions  should  be  given  in  regard  to  the  wash- 
ing of  hospital  clothing,  particularly  when  patients  with  other 
diseases  are  treated   in  the  same  institution. 

Soiled  outer  garments,  underwear,  and  bed-linen  must  be  immediately 
removed  from  the  wards,  sprinkled  with  a  3  per  cent,  solution  of  carbolic 
acid,  or,  better,  with  a  solution  of  lysol,  and  kept  in  earthenware  or  tin 
receptacles  with  perforated  lids  until  such  time  as  they  can  be  taken  away, 
which  should  be  done  with  the  greatest  possible  despatch.  The  method  of 
keeping  the  soiled  clothing  in  water-tight  and  air-tight  bags,  which  answers 
very  well  in  the  case  of  typhoid  fever,  cholera,  and  dysentery,  I  do  not  care 
to  recommend  for  typhus  fever  patients,  for  I  have  great  faith  in  the  disin- 
fecting power  of  the  atmospheric  air,  and  believe  that  objects  that  have  been 
kept  from  contact  with  the  air  are  doubly  dangerous. 

In  the  interest  of  laundry  employees  it  is  advisable,  and  indeed  it  is 
absolutely  necessary,  if  the  clothing  of  other  patients  is  washed  in  the  same 
laundry,  to  disinfect  the  clothing  of  typhus  fever  ]mtieuts  by  means  of 
boiling  or  exposure  to  superheated  steam  before  beginning  the  process  of 
washing. 

In  order  to  prevent  the  clothing  from  becoming  spotted  by  the  boiling  it 


608  TYPHUS  FEVER. 

is  well  to  use  a  weak  solutiou  of  soapsuds  with  a  little  soda  and  petroleum 
(Gartner).  This  precaution,  however,  will  not  prevent  materials  soiled 
with  mud,  blood,  or  pus  from  becoming  spotted,  but  even  liospital  authori- 
.ties  will  resign  themselves  to  this  inconvenience  when  the  great  prophylactic 
value  of  the  precaution  has  been  made  clear  to  them.  When  typhus  fever 
patients  are  treated  in  private  houses  the  question  of  washing  is  exceedingly 
complicated  and  >vill  depend  largely  on  the  facilities  at  hand. 

If  the  inhabitants  and  the  authorities  can  be  persuaded  to  do  their 
part,  it  will  usually  be  possible  to  utilize  public  institutions  for  the  dis- 
infection of  clothing,  and  perhaps  even  the  laundries  of  hospitals,  con- 
sidering the  small  number  of  eases  usually  treated  in  private  houses, 
can  be  used  for  this  purjiose. 

A  safe  method  of  disinfecting  washing,  bed-linen,  and 
outer  clothing  consists  in  the  use  of  live  steam  in  the  well-known 
apparatus  now  in  use  everywhere.  Furs  and  leather  garments  cannot 
be  subjected  to  this  process,  as  they  are  completely  destroyed  by  it. 
They  must  be  carefully  treated  with  a  5  per  cent,  carbolic  acid  solution 
and  exposed  to  the  air  for  a  number  of  days. 

It  may  be  interesting  to  note  that  during  my  experience  in  Moabit, 
which  antedates  the  introduction  of  steam  sterilization  bj  Koch,  we 
succeeded  in  completely  disinfecting  clothing  and  miderwear  by  exposing 
them  for  from  one  to  two  hours  to  a  temperature  of  110°  to  112° 
C.  in  a  specially  constructed  apparatus.  The  clothing  was  not  tied 
together  in  bundles,  but  hung  free,  or  at  least  was  arranged  in  loose 
pUes  and  thus  exposed  to  the  heat  much  in  the  same  way  as  the  mate- 
rial is  arranged  in  the  present  method  of  treatment  with  live  steam. 

The  disinfection  of  beds,  like  that  of  the  body  linen,  should  be  done 
by  live  steam.  Blankets,  pillows,  and  mattresses  of  any  kind  may  be 
exposed  without  suffering  any  damage.  Even  iron  bedsteads,  which 
should  always  be  of  the  folding  variety  in  epidemic  hospitals,  may  be 
exposed  to  hot  steam.  Wooden  bedsteads  should  be  taken  apart  and 
thoroughly  cleansed  ^^^th  carbolic  acid  or  lysol  solutions  and  then 
exposed  to  the  air  for  a  number  of  days. 

In  fitring  up  a  temporary  hospital,  and  whenever  sufficiently  large  disin- 
fecting apparatus  cannot  be  detained,  the  beds  should  be  provided  with 
straw  mattresses,  the  hardness  of  which  may  he  overcome  by  spreading 
several  blankets  upon  them.  As  the  material  with  which  these  mattresses 
are  filled  is  of  little  value,  they  may  be  destroyed  by  fire  ;  blankets,  cover- 
ings, and  other  materials  may  be  disinfected  by  boiling  ;  blankets  can  be 
disinfected  by  merely  exposing  them  to  the  sun  for  a  few  days. 

The  care  of  other  articles  used,  by  patients  is  less  important 
in  typhus  fever  than  in  many  other  acute  infectious  diseases.     Plates^ 


PROPHYLAXIS.  •         009 

glasses,  spoons,  and  forks  require  only  washing  in  hot  water,  as  the 
coutagium  does  not  adhere  to  objects  with  a  smooth,  non-j)orous  surface. 
Bed-pans,  specimen  glasses,  and  water-closets  should,  of  course,  be  care- 
fully cleansed  and  disinfecited  with  lysol  solution  or  chlorid  of  lime. 
They  are  doubtless,  however,  much  less  dangerous  than  in  typhoid 
fever,  since  the  bacillus  of  typhoid  fever  is  found  chiefly  in  the  feces 
and  urine. 

The  exact  relation  of  the  feces  and  urine,  as  well  as  that  of  the  other 
excretions  of  the  body,  to  the  poison  of  typhus  fever  Ls  imperfectly 
known.  The  stools  I  believe  to  be  least  dangerous,  while  the  urine, 
sputum,  and  perspiration  deserve  more  careful  attention  in  the  matter 
of  disinfection.  Accordingly  I  always  add  some  disinfectant  to  the  water 
used  in  washing  patients  after  profuse  perspiration,  or  even  have  them 
sponged  with  brandy. 

Typhus  cadavers  do  not  appear  to  be  specially  contagious  :  not 
more  so  at  least  than  other  inanimate  objects  to  which  the  poison  adheres 
mechanically.  It  was  my  practice  to  wash  the  cadavers  with  a  5  per 
cent,  carbolic  acid  solution  and  wrap  them  in  cloths  saturated  with  the 
same  solution ;  this  I  believe  to  be  all  that  is  necessary.  Although  we 
held  a  great  number  of  autopsies,  and  had  but  a  small  room  in  which  to 
perform  them,  I  never  had  a  case  of  infection  among  the  physicians  or 
attendants. 

The  disinfection  of  wards  or  private  sick-rooms  after  the 
patient  has  recovered  or  died  must  be  carried  out  with  scrupulous  care. 
The  peculiar  character  of  the  poison  of  typhus  fever  calls  for  certain 
deviations  from  the  ordinary  procedure  adopted  in  such  cases. 

In  the  first  place  the  rooms  should  not  be  kept  closed  for  a  time,  as 
is  the  practice  ui  other  diseases ;  but,  on  the  contrary,  they  should  be 
kept  open  for  a  number  of  days  and  well  ventilated  by  throwing  open 
windows,  doors,  dampers,  and  other  vent-holes.  In  the  section  on 
Etiology  I  took  occasion  to  remark  that  ventilation  is  the  most  powerful 
agent  we  have  with  which  to  combat  the  poison  of  the  disease. 

Disinfection  of  Furnishings. — After  ventilation  has  been  com- 
pleted the  furniture,  pictures,  and  other  ornaments  on  the  walls  are 
removed,  and  the  walls,  as  well  as  the  ceiling,  subjected  to  a  careful  dis- 
infection. The  disinfection  of  the  ceiling  is  much  more  necessar}^  in 
typhus  fever  than  in  many  of  the  other  acute  infectious  diseases.  If 
the  walls  and  ceiling  are  papered,  they  should  be  rubbed  do^vn  T^^th 
bread-crumbs  that  are  afterward  carefully  collected  and  burned.  If  the 
walls  are  painted  in  oil  colors,  they  should  be  brushed  down  with  a  solu- 
tion of  carbolic  acid  or  lysol.     If  they  are  whitewashed,  they  should  be 

39 


(ilO  TYPHUS  FEVER. 

scraped  off,  disinfected  \\'ith  chlorid  of  limo,  and  treated  to  a  fresh  coat 
of  whitewash. 

The  floor  is  scrubbed  Ciirefully  with  soft  soap  and  carbolic  acid, 
special  attention  being  paid  to  the  joints  ;  it  is  afterward  rubbed  off  and 
waxed  or  painted. 

Unpainted  furniture  and  furniture  ])ainted  with  oil  should  be  washed 
with  a  3  to  5  per  cent,  solution  of  carbolic  acid.  Varnished  and  pol- 
ished pieces  are  best  cleaned  with  bread.  The  same  method  is  eniplo}'ed 
with  varnished  pictures,  mirrors,  oil  paintings,  and  their  frames. 

If  the  furniture  is  upholstered,  the  coveiing  should  be  removed, 
horsehair  should  be  disinfected  by  boiling,  and  other  inexpensive  mate- 
rial burned.  Simple  spongmg  or  sprinkling  of  the  upholstered  surface 
with  carbolic  acid,  which  may  suffice  after  many  other  mfectious  dis- 
eases when  there  has  been  no  direct  ])ollution,  is  utterly  inadequate  to 
destroy  the  poison  of  typhus  fever. 

As  it  is  exceedmgly  difficult  to  disinfect  woolen  materials  and  uphol- 
stered olijects  generally,  it  is  advisable  to  remove  all  but  the  most  neces- 
saiy  objects  from  the  sick-room  and  adjoinmg  rooms  from  the  beginning. 

In  the  disinfection  of  ships,  railroad  cars,  and  vehicles  that  have 
been  used  by  typhus  fever  patients,  the  methods  prescribed  for  dwellings 
and  furniture  will  suffice  with  proper  modifications. 

Disinfection  of  hospital  wards  by  formaldehyd,  which  has  recently 
been  recommended,  has  never  been  tried  in  typhus  fever.  From  what 
we  know  of  the  nature  of  the  poison  it  seems  probable  that  this  method 
would  be  efficient.  It  is  much  to  be  hoped  that  careful  experiments 
will  be  made  during  the  next  epidemic,  since,  if  they  prove  successful, 
the  present  rather  complicated  measures  will  be  immensely  simplified. 

The  disinfection  of  private  houses  cannot  be  carried  out  successfully  l)y 
any  one  who  is  not  an  expert.  Even  intelligent  and  well-informed  persons 
who  have  not  been  specially  trained  are  practically  always  found  to  l)e 
unequal  to  the  task.  In  all  the  larger  cities  we  now  have  regular  disinfect- 
ing officials,  whose  services  can  be  obtained  by  application  to  the  Board  of 
Health  or  to  the  hospital  authorities.  In  smaller  places  the  hospital  attend- 
ants and  nurses  should  be  instructed  properly  and  drilled  in  the  necessary 
methods. 

Regulations  Regarding  the  Discharge  of  Convalescents. 

— Before  allowing  convalescents  to  return  to  their  fiimilies  and  to  private 
life  it  should  be  remembered  that  they  are  capable  of  cariying  the 
poison  if  the  necessary  precautions  have  been  neglected,  just  as  other 
healthy  persons  may  do  if  they  have  come  in  contact  'SA'ith  patients  or 
have  been  in  an  infected  ward. 

For  several  days  before  thev  are  discharged  convalescents  should 


PROPHYLAXIS.  ■  611 

take  warm  baths  with  carbolized  soap  and  water,  careful  attention  being 
given  to  the  proper  cleansing  and  disinfection  of  the  hair,  beard,  and 
other  hairy  portions  of  the  body.  The  last  bath  should  be  taken,  if 
possible,  at  a  distance  from  the  liospital  in  a  place  that  has  not  been 
contaminated  by  patients  or  their  belongings.  After  they  have  taken 
this  final  bath,  the  convalescents  are  to  dress  in  new  clothing,  or  in  their 
old  clothing  if  this  has  been  carefully  disinfected  and  preserved  from 
contact  with  the  poison  of  the  disease. 


TREATMENT. 

SPECmC    TREATMENT. 

Up  to  the  present  time  there  have  been  no  noteworthy  attempts  at 
specific  treatment  of  typhus  fever  in  the  modern  sense. 

Even  the  epidemic  appearance  of  the  disease  in  France  in  1893  does 
not  appear  to  have  led  to  any  careful  attempts  in  this  direction,  although 
a  number  of  French  physicians  were  at  the  time  well  trained  and  com- 
petent to  make  the  necessary  experiments. 

The  fact  that  it  is  so  dangerous  a  disease  that  the  mortality  is  three 
times  as  great  as  it  is  from  typhoid  fever  should  induce  us  to  devise  new 
and  more  efficient  methods  of  treatment  than  those  at  present  in  use. 

Even  the  manifest  difficulties  eucountered  in  the  study  of  the  nature 
and  life-history  of  the  cause  of  typhus  fever  and  the  absence  of  any  definite 
knowledge  in  regard  to  it  should  not  deter  us  in  future  epidemics  from 
making  experiments  in  immunization  and  serotherapy.  We  ought  to  feel 
encouraged  by  the  results  of  vaccination  in  preventing  small-pox  and  by 
the  famous  achievements  of  Pasteur  in  the  treatment  and  prevention  of 
rabies.  Whether  experiments  in  connection  with  typhus  fever  will  also  be 
crowned  by  success  and  of  what  nature  the  results  of  these  experiments  will 
be  cannot,  of  course,  be  predicted  to-day.  I  have  already,  in  the  chapter  on 
the  treatment  of  typhoid  fever,  had  occasion  to  point  out  the  fallacy  of  reason- 
ing by  analogy,  and  I  feel  impelled  to  repeat  the  warning  in  this  place. 

As  opinions  in  regard  to  the  nature  of  typhus  fever  changed,  numer- 
ous attempts  were  made  to  shorten  or  abort  the  disease  by  blood-letting, 
by  emetics,  and  by  a  long  series  of  specific  drugs,  such  as  quinin  and 
others.     All  these  methods  have  now  been  abandoned. 

An  interesting  paragraph  on  this  subject  is  found  in  Hildenbrand's  famous 
niouograph,  which  dates  from  the  beginning  of  the  present  century,  and  I  am 
tempted  to  quote  a  few  especially  pregnant  sentences  from  this  work.' 

"After  a  dispassionate  survey  of  all  these  hypothetic  methods  of  treat- 
ment, it  is  noted  at  once  how  short-lived  they  were,  how  little,  therefore,  was 
their  true  value,  and  how  inadequate  they  were  in  practice.  We  may  in 
the  future  expect  as  many  more  such  doctrines  and  systems  of  therapeutics 
as  there  will  be  hot-heads  and  visionaries  in  our  art.  But  if,  on  the  con- 
trary, we  follow  the  path  of  observation  and  successful  experience  in  these 
cases — in  other  words,  the  path  of  empiricism  guided  by  reason — our  free 
and  untrammeled  judgment  will  lead  us  on  to  new  and  better  views  than 
can  be  hoped  for  from  a  bi-ain  that  is  ruled  by  hypotheses." 

^  Loc.  cit.,  p.  178. 
612 


TREATMENT.  613 

The  most  successful  empiriciil  method  of  treatment  at  the  present  day 
directs  attention,  above  all,  to  the  proper  care  of  the  patient  in  the 
broadest  sense,  including  appropriate  diet  in  all  stages  of  th(!  disease, 
with  a  due  regard  to  individual  peculiarities,  and  to  the  treatment  of 
the  fever  and  its  concomitant  symptoms,  and  also  special  localizations 
and  complications  of  the  disease,  with  physical  and  medicinal  agents. 

GENERAL  TREATMENT,  NURSING,  AND   DIET. 

Owing  to  the  intensity  of  the  initial  phenomena,  even  in  cases  that  later 
turn  out  to  be  mild,  it  is  rarely  necessary  to  order  the  ])atients  to  bed  ; 
they  are,  without  exception,  so  prostrated  from  the  very  beginning  that 
they  cannot  keep  on  their  feet,  and  therefore  go  to  bed  of  their  own  accord. 

It  goes  without  saying  that  absolute  rest  in  bed  during  the 
entire  course  of  the  disease  and  for  at  least  a  week  after  the  complete 
disappearance  of  fever  should  be  an  absolute  rule,  as  it  is  in  any  other 
severe  infectious  disease. 

Patients  should  not  be  allowed  to  sit  up,  even  while  the  bed-clothing 
is  being  changed.  They  should  never  be  allowed  to  get  out  of  bed  to 
void  feces  or  urine,  but  should  be  compelled  to  use  the  bed-pan  and 
urine  bottle  from  the  very  beginning. 

In  the  arrangement  of  the  bed  the  former  habits  of  the  patients 
may  be  consulted  to  a  certain  extent.  It  should  be  moderately  cool 
and  easy  to  clean  and  air.  If  at  all  feasible,  a  second  bed  should  be 
prepared,  so  as  to  allow  the  patient  to  change.  If  a  prolonged  and 
severe  case  is  expected,  it  is  well  to  provide  a  water-bed  from  the  outset. 

The  sick-room  should  be  as  large  and  airy  as  possible.  It  should 
afford  the  greatest  possible  amount  of  rest  to  the  patient  and  allow  the 
strictest  isolation. 

The  practice  of  darkening  the  room,  formerly  recommended,  is  as 
harmful  as  is  excessive  illumination.  It  is  only  necessary  to  place  the 
patient  with  his  face  turned  away  from  the  window,  which  need  not 
be  covered  with  a  shade. 

The  hospital  attendants  should,  if  possible,  be  individuals  who  have 
been  rendered  immune  by  an  attack  of  the  disease  ;  although  such 
persons  are  usually  protected  against  a  second  attack,  they  should,  never- 
theless, be  carefully  isolated  from  healthy  persons,  for  they  are  veiy  likely 
to  spread  the  disease  by  means  of  the  poison  that  adheres  to  their  cloth- 
ing and  other  personal  effects. 

During  a  large  epidemic  and  in  places  where  the  disease  is  not  endemic 
it  is  difficult,  if  not  impossible,  to  procure  immunes  for  hospital  attendants. 
The  contagiousness  of  the  disease  and,  in  case  of  infection,  the  severity  of 


614  TYPHUS  FEVER. 

its  course,  may  be  somewhat  oombated  by  protecting  the  atteudauts  from 
excessive  exertion,  by  careful  attention  to  their  diet  and  personal  cleanli- 
ness, and,  above  all,  by  insisting  on  the  prophylactic  value  of  careful  venti- 
lation of  the  wards.  After  the  work  of  hospital  attendants  is  finished,  they 
should  be  subjected  to  a  strict  quarantine,  lasting  a  little  longer  than  the 
average  period  of  incubation,  before  they  are  allowed  to  mingle  with  the 
general  population. 

AVhenever  strict  isolation  of  tlie  patient  is  iinpos.^ible,  lii.s  imme- 
diate admission  to  a  hospital  should  be  insisted  upon.  This  point 
will  be  discussed  in  detail  further  on. 

If  the  patient  can  be  nursed  at  home,  the  first  question  to  be  decided 
is  what  arrangements  arc  necessary  for  his  own  welfiire  and  to  guard 
against  the  spread  of  the  disease.  The  sick-room,  in  the  first  place, 
should  contain  only  what  is  indispensable  for  the  care  of  the  patient. 
MuTors,  wall-paper  of  glaring  design,  conspicuous  pictures,  and  any 
other  brightly  colored  or  other^vise  unj^leasantly  prominent  objects 
should  be  covered  or  removed.  This  precaution  Ls  more  necessary  e\en 
than  in  typhoid  fever.  Any  physician  of  experience  loiows  how  such 
objects  feed  the  imagination  of  the  delirious  patient,  and  to  what  an 
extent  they  enter  into  his  hallucinations,  aggravate  his  delirium  to  the 
point  of  mania,  and  thus  give  rise  to  incalculable  harm. 

I  remember  a  patient  who  smashed  into  fragments  a  mirror  that  hung 
opposite  his  bed,  because  he  mistook  his  own  image  for  an  enemy,  and 
another  who  jumped  through  the  window  because  he  was  terrified  by  a 
painted  head,  in  the  side  of  a  porcelain  stove,  which  he  thought  was  alive 
and  seemed  to  him  to  bear  a  frightful  expression. 

All  woolen  objects,  blankets,  window  curtams,  rugs,  upholstered 
furniture,  and  other  objects  to  which  the  poison,  as  we  know,  clings 
with  the  greatest  obstinacy,  should  be  removed  at  once  from  the  room. 
If  circumstances  permit,  the  carpets  should  be  replaced  by  linoleum, 
which  is  easily  cleansed  and  disinfected. 

These  precautions,  often  carried  out  with  difficulty  m  private  prac- 
tice, are  properly  observed  in  all  well-regulated  hospitals,  but  there  are 
many  directions  to  be  observed  in  regard  to  the  placing  of  the  patients. 

Removal  to  Hospitals. — Whenever  it  is  at  all  possible,  typhus 
fever  patients  should  not  be  admitted  to  general  hospitals,  but  if  this 
cannot  be  avoided,  it  must  at  least  be  remembered  that  mere  isolation  in 
special  wards  near  those  occupied  by  other  patients  does  not. suffice. 
The  proper  degree  of  isolation  can  be  obtained  only  by  placing  the 
patients  in  a  special  ward  at  some  distance  from  all  the  others — if  possi- 
ble, it  should  be  at  the  top  of  the  building  and  provided  with  a  separate 
entrance. 

It  is  always  much  better  to  have  special  epidemic  hospitals  or  isolated 


TREATMENT.  615 

buildings  connected  with  the  general  hospitid,  such  as  are  in  use  in  all 
large  cities. 

In  the  construction  of  buildings  of  this  kind,  designed  for  the 
reception  of  small-pox  and  typhus  fever  patients,  the  barracks-system  is 
to  be  preferred.  If  no  permanent  pest-house  is  available,  wards  can  be 
constructed  on  this  system  easily  and  rapidly ;  many  of  the  best  epidemic 
hospitals  to-day — I  need  refer  only  to  the  lazaretto  in  Moabit — began 
their  existence  as  makeshifts  of  this  kind. 

Ventilation. — The  barracks-system  affords  the  readiest  means  of 
carrying  out  perfect  ventilation,  so  necessary  for  both  the  patients  and 
their  attendants. 

The  windows  should  be  open  by  day  and  night ;  in  winter  there 
should  be  correspondingly  increased  heating  facilities.  During  the 
milder  seasons  of  the  year  I  make  a  practice  of  keeping  my  patients 
in  the  open  air,  properly  protected  against  sun  and  rain. 

Open-air  Treatment. — I  cannot  say  too  much  in  favor  of  the' 
open-air  treatment.  Although  the  hope  I  entertained  in  the  beginning  of 
reducing  the  fever  by  this  means  was  never  realized,  the  procedure  proved 
to  have  a  very  favorable  effect  on  the  nervous  system,  which  is  always  so- 
severely  implicated  in  typhus  fever.  The  patients  became  quiet,  and! 
the  symptoms  of  the  initial  stage — the  violent  headache  and  insomnia — 
were  more  favorably  influenced  by  the  open-air  treatment  than  by  any 
other  means.  The  intensity  of  the  delirium  was  held  in  check,  and  the 
mental  condition  of  stuporous  and  comatose  patients  often  seemed  to  be 
very  favorably  influenced. 

The  open-air  method  is  of  value  not  only  as  a  symptomatic,  but  also 
as  a  directly  curative,  treatment,  since  we  known  that  the  chief  danger 
to  the  central  nervous  system  lies  in  excessive  excitation  or  excessive 
depression. 

Aside  from  the  benefit  to  the  patient,  thorough  ventilation  and  the 
open-air  treatment  afford  the  most  effectual  means  of  guarding  against 
the  spread  of  the  disease. 

It  is  to  the  strict  use  of  these  measures  that  I  attribute  the  fact  that  not  a 
single  physician  was  infected,  and  that  the  percentage  of  hospital  attendants 
who  contracted  the  disease  was  conspicuously  low  during  the  three  years 
from  1876  to  1878,  when  all  the  cases  of  typhus  fever  occurring  in  Berlin 
were  admitted  to  Moabit  and  treated  by  the  open-air  method.  The  great 
majority  of  the  hospital  infections  that  did  occur  might  have  been  avoided 
if  the  individuals  had  not  neglected  my  instructions.  I  had  issued  strict 
orders  that  the  necessary  baths  were  to  be  given  exclusively  in  the  large 
wards,  instead  of  in  the  narrow  and  poorly  ventilated  bath-rooms.  Most 
of  the  attendants  who  contracted  the  disease  had,  merely  out  of  laziness,, 
repeatedly  neglected  to  obey  this  order. 


61 G  TYPHUS  FEVER. 

I  may  remark  that  I  am  not  alone  iu  maiutainiug  these  views.  Eveu 
the  older  authoi's,  Hiklenbrand  iii  particular,  advocated  the  method  of 
treatment  with  cool,  fresh  air.  I  am  pleased  to  note  that  several 
physicians  after  me  have  recommended  tiie  open-air  treatment  as  the 
most  elticacioiis  anti])yretic  remedy.  The  excellent  \\()rks  of  Kacze- 
rowski,  published  in  1878  and  1879,  and  the  statistics  collected  by 
Barrault  during  the  Lille-Paris  epidemic  of  1893,  are  particularly  worthy 
of  mention.  The  latter  goes  so  far  as  to  affirm  that  he  actually  reduced 
the  mortality  by  energetic  open-air  treatment. 

Diet. — The  diet  in  typhus  fever  should  be  based  on  the  same  princi- 
ples as  those  that  guide  us  in  the  treatment  of  the  acute  exanthemata 
and  not  on  those  that  obtain  in  the  treatment  of  typhoid  fever  and  the 
other  infectious  diseases  especially  characterized  by  intestinal  lesions. 

The  choice  of  food  iu  typhus  fever  is  limited  only  by  the  deleterious 
eifects  of  the  toxin  on  the  various  secretions  and  mechanisms  of  diges- 
tion. 

During  the  initial  stage,  when  appetite  is  absent  in  nearly  all  patients, 
when  every  form  of  nourishment  is  repulsive  to  them  and  they  are  tor- 
mented by  a  constant  desire  to  vomit,  and  also  during  the  entire  febrile 
stage,  the  diet  should  consist  exclusively  of  liquids. 

Of  all  foods,  milk  is  the  one  that  most  nearly  fulfills  the  require- 
ments in  the  matter  of  supplying  albumin,  carbohydrates,  and  fat,  and 
it  is  to  be  regretted  that  a  large  number  of  patients,  especially  during 
the  febrile  period,  are  unable  to  take  it,  at  least  in  unmodified  form. 
The  phvsician  should  not,  however,  allow  himself  to  be  too  easily 
deterred  from  prescribing  it.  In  some  cases  the  milk  may  be  rendered 
palatable  by  diluting  it  wdth  Seltzer  or  lime-water ;  in  other  cases  the 
addition  of  cognac  or  of  common  salt  may  be  found  to  answer.  A  very 
good  plan  consists  of  mixing  the  milk  with  semifluid  substances,  such 
as  sago,  rice,  farina,  arrow-root,  Kindennehl,  and  the  like,  because  it 
affords  the  best  means  of  preventing  the  formation,  in  the  stomach,  of 
coarse  coagula  that  interfere  so  much  with  digestion.  An  equally 
efficient  breaking-up  of  the  casein  takes  place  in  buttermilk,  which 
many  patients  find  palatable.  Again,  the  patient's  objections  are  some- 
times successfully  overcome  by  giving  the  milk  in  the  form  of  kephyr. 
The  carbonic  acid  contained  in  this  is,  for  obvious  reasons,  much  less 
objectionable  in  typhus  than  it  occasionally  proves  to  be  in  typhoid 
fever. 

In  some  cases  I  have  ]irescribed  cold  or  tepid  whey,  and  have  often 
obtained  very  favorable  results  from  this  when  there  was  intense  catarrh 
of  the  respiratory  passages. 


TREATMENT.  617 

If  the  milk  is  well  borne;  it  may  witli  advantage  l)e  enriched  hy  an 
admixture  of  cream. 

Apart  from  milk,  the  most  useful  foods  are  the  carbohydrates,  given 
in  a  fluid  form,  especially  as  thick  soups.  As  has  been  said  in  connec- 
tion with  the  treatment  of  typhoid  fever,^  in  order  to  render  such  a  diet 
palatable  for  any  length  of  time  the  substances  used  must  frequently  be 
varied.  Oatmeal,  rice,  farina,  sago,  green  wheat,  tapioca,  and  aleuro- 
nat  flour  may  be  used  to  break  the  monotony  of  the  liquid  diet.  Even 
during  the  height  of  the  fever  soups  containing  evaporated  fruits  or, 
better,  soups  prepared  with  Hartenstein's  leguminose,  may  be  permitted. 

It  is  well  to  alternate  the  thick  soups  with  clear  broth  containing  eggs, 
or  we  may  add  Leube-Rosenthal's  meat-solution,  sweet-breads,  calves-brains, 
chicken,  or  pigeon  ;  this  may  be  done  during  any  stage  of  typhus  fever. 

It  should  be  distinctly  understood  that  eggs  are  better  borne,  as  a 
rule,  by  typhus  patients  than  by  patients  suifering  from  typhoid  fever. 
As  many  as  three  or  four  eggs  may  be  taken  in  the  twenty-four  hours, 
either  stirred  m  with  the  soup — the  best  method — or  soft  boiled,  or 
beaten  up  with  a  small  quantity  of  bouillon,  sweet  wine,  or  cognac  (egg- 
nog). 

It  is  customary  at  the  present  day  to  enrich  the  soups  by  the  addition  of 
all  kinds  of  artificial  albuminous  foods  and  condiments,  such  as  somatose, 
nutrose,  eucasin,  meat  peptones,  and  various  meat  extracts,  among  which 
may  be  mentioned  Liebig's  extract  and  Valentine's  meat  juice,  the  latter 
containing  very  little  albumin. 

On  the  whole,  I  prefer  beef-tea  prepared  in  the  house  to  the  artificial 
meat-extracts,  and  believe  that  for  patients  whose  sensibilities  are  so  dulled 
by  the  disease  that  they  are  not  disgusted  by  the  appearance  and  unpleasant 
odor  of  sucGus  carnis  recens  expressus  (beef-juice),  the  latter  preparation, 
which  also  contains  extractives  of  meat  albumin  in  a  very  digestible  form, 
should  be  used  freely. 

The  SUCGUS  Garnis  can  readily  be  prepared  with  Klein's  meat  press, 
either  in  the  hospital  or  in  a  private  house.  Patients  who  are  fully  con- 
scious sometimes  take  to  it  quite  kindly  if  it  is  mixed  with  wine  or  bouillon 
and  served  in  a  green  glass  to  disguise  the  bloody  color. 

Patients  in  good  mental  condition  who  are  able  to  chew  and  swallow 
may  be  allowed  solid  food  in  addition  to  the  liquid  preparations  during 
any  stage  of  the  disease,  even  during  the  height  of  the  fever.  They 
may  be  given  rolls.  Zwieback,  cakes,  or  perhaps  raw  chopped  meat, 
spring  chicken,  squab,  and  the  like. 

The  general  rule  is  to  feed  patients  regularly  every  two  to  three 
hours,  a  little  at  a  time,  and  to  endeavor  by  all  possible  means  to  induce 
them  to  eat  when  they  are  stuporous.  Patients  should  receive  some 
food  two  or  three  times  during  the  night^ — for  example,  milk,  bouillon 

1  Loe.  cit.,  p.  426. 


618  TYPHUS  FEVER. 


Avitb  eg<j,-,  aiitl  tlu'  like.  It  is  woll  to  offer  them  some  little  refreshment 
between  meal- — wine  or  meat-jelly  in  teaspoonful  doses,  or,  what  is 
e(|nally  as  good,  Brandt's  essenee  ot"  beef. 

In  the  same  way  the  patients  sbonld  receive  drinks  at  regnlar  inter- 
vals, even  if  they  mnst  be  persnaded  to  take  them.  Ordinary  water  is 
best,  but  Seltzer,  Giesshiibler,  or  Biliuer  may  be  given.  Artificial 
mineral  watei-s  should  be  given  only  after  effervesceuce  has  subsided. 

A  little  fruit-juice,  either  lemon  or  nispherry,  may  be  added  to  the 
water,  but  if  j)ossil)le  the  juice  should  he  sweetened  with  saccharine  instead 
of  sugar.  If  alcohol  is  indicated,  the  water  may  he  mixed  with  cognac  or 
wine.  Cold  tea,  coffee,  or  bouillon  may  with  advantage  be  given  either  in 
the  place  of,  or  alternating  with,  the  hevei-ages  mentioned.  All  drinks 
should  he  iced,  or  at  least  cold,  unless  this  is  contraindicated  by  some  especial 
gastric  or  intestinal  condition. '  With  proper  care,  the  mouth  and  the  gums 
of  the  patient  should  never  become  dry,  and,  of  course,  they  should  be  kept 
scrupulously  clean. 

In  regard  to  the  administration  of  alcoholic  liquors  opinions  have 
undergone  a  marked  change  in  the  last  few  years.  The  practice  of 
administering  alcohol  regularly  and  in  large  quantity  in  febrile  diseases 
has  been  almost  universally  abandoned. 

With  a  nutritious  and  well-regulated  diet  alcohol  may  usually  be  dis- 
pensed with  in  typhus  fever,  at  least  as  a  part  of  the  regular  treatment. 

It  is  best  to  withhold  alcohol  until  its  use  is  indicated,  when  it  will 
be  doubly  efficacious,  especially  when  used  to  stimulate  a  failing  heart. 
In  anv  condition  of  collapse  the  indication  for  alcohol  is  urgent,  and  its 
free  use  may  be  the  means  even  of  saving  life. 

It  is  scarcely  necessaiy  to  mention  that  a  heavy  drinker  or  one  who 
has  been  accustomed  to  the  regular  use  of  a  moderate  amount  of  spiritu- 
ous liquors  must  not  be  deprived  entirely  of  alcohol  during  the  disease. 
Its  administration  often  has  a  vety  good  effect  when  the  patient  is  rest- 
less and  cannot  sleep,  while  its  complete  withdrawal  not  infrequently 
induces  violent  delirium  and  other  severe  symptoms.  These  patients 
may  be  allowed  light  Rhine  wines  or  Moselle,  or  even  well-matured 
beer  of  a  good  quality,  especially  Pilsner. 

Usually  with  the  beginning  of  defervescence,  and  almost  regularly 
afler  the  period  of  defervescence  is  over,  the  patient's  appetite  rapidly 
begins  to  improve.  Since  there  are  no  counterindications  on  the  part 
of  the  intestine,  as  in  typhoid  fever,  there  is  no  objection  to  gratifying 
the  patient's  appetite  by  allowing  him  semiliquid  and  solid  food  in 
addition  to  milk  and  soups.  Such  articles  as  roast  veal,  roast  beef, 
roast  mutton,  venison,  and  poultry,  with  rice,  flirina,  mashed  potatoes, 
or  green  vegetables,  may  be  permitted.     The  ordinary  diet,  with  the 


TREATMENT.  619 

exception  of  articles  which  are  especially  difficult  to  digest,  may  be 
resumed  before  long.  This  is  a  good  plan,  es])ecia]ly  for  persons  in 
moderate  circumstances  wlio  must  return  to  their  work  and  their  former 
mode  of  life  within  a  short  time. 

Among  the  special  methods  of  treatment,  those  that  are  directed 
toward  combating  the  febrile  condition  and  its  consequences — the  SO- 
called  antipyretic  methods — occupy  the  first  place. 

The  fact  that  these  methods  have  not  been  discussed  in  detail  in  their 
bearing  on  typhus  fever  is  owing,  probably,  to  the  great  press  of  work 
and  the  many  demands  on  the  physician  in  times  of  extensive  epidemics, 
so  that  he  has  neither  the  opportunity  nor  the  time  for  careful  observa- 
tion. As  a  rule,  however,  most  physicians  place  much  reliance  on  these 
methods,  especially  on  hydrotherapy  and  the  use  of  antipyretic  drugs. 

I  have  already  spoken  of  the  undoubted  value  of  fresh,  frequently 
renewed  air  in  combating  the  fever.  It  is  to  be  hoped  that  in  future 
epidemics  the  open-air  treatment  will  be  more  extensively  employed  in 
suitable  cases.  I  am  inclined  to  go  so  far  as  to  keep  the  patients  in  the 
open  air  even  during  the  night,  providing  them,  of  course,  with  the 
proper  protection. 

Among  the  various  uses  of  hydrotherapy,  the  simplest  and  the 
most  indispensable  methods  are  bathing,  local  application  of  cold,  and 
the  use  of  the  water  mattress. 

In  severe  cases,  as  has  been  stated  elsewhere,  it  is  best  to  put  the 
patient  on  a  water-bed  from  the  beginning.  The  mechanical  reduction 
in  temperature  may  be  still  further  increased  by  changing  the  Avater 
several  times  a  day,  a  procedure  that  can  easily  be  carried  out  without 
altering  the  patient's  position.  The  water  should  not  be  colder  than 
18°  to  20°  C.  No  advantage  is  secured  from  the  use  of  water  of  a 
lower  temperature,  or  even  iced  water,  as  has  been  recommended,  and  it 
is  certain  to  distress  the  patient. 

In  all  severe  cases  an  ice-cap  should  be  placed  on  the  head  from  the 
beginning  and  during  the  entire  febrile  period.  If  the  patient  is  very 
irritable,  the  use  of  Leiter's  tubes  is  preferable,  for  they  avoid  the  dis- 
turbance of  changing  and  refilling  the  ice-cap. 

When  there  is  severe  headache,  especially  in  the  beginning  of  the 
disease,  a  small  pillow  filled  with  iced  water  is  valuable.  Both  the  ice- 
cap and  the  water  mattress  are  reliable  means  for  combating  the  insomnia, 
which  is  often  very  troublesome. 

An  ice-bag  may  often  with  advantage  be  applied  to  the  precordial 
region,  especially  when  the  pulse  is  very  rapid  and  irregular  and  the 
heart  begins  to  fail. 


G2U  TYPHUS  FEVER. 

E\-erv  patient  should  bo  tliorouiilily  sponged  two  or  three  times  a 
day.  The  jiraetiee  of  French  physicians  of  adding  a  little  vinegar  to 
the  water  will  often  be  found  i>rateful.  Under  certain  circumstanees 
partial  or  total  wet-packs  may  be  employed  after  the  sponging.  lu 
many  cases  it  may  be  advisable  to  use  them  in  place  of  the  sponging, 
but  they  must  be  carefully  regulated  to  suit  mdividual  conditions  in  the 
matter  of  tem]ierature,  duration,  and  extent  of  body-surface  to  which 
they  are  apj)lied. 

Ill  many  patients  a  cool  or  lukewarm  wet-pack  a])plicd  to  the  trunk 
and  lower  extremities  during  the  tirst  half  of  the  night  is  successful  in 
allaying  restlessness  and  inducing  sleep. 

As  a  rule,  one  should  guard  against  the  too  frequent  use  of  very  cold 
packs,  as  they  have  an  undesirable  exciting  effect  on  many  patients. 

Treatment  by  Baths. — Although  opinions  may  differ  as  to  the 
number  of  cool  or  lukewarm  baths  that  it  is  desirable  to  employ,  and  as 
to  the  way  in  which  they  act,  no  one  will  deny  the  value  of  employing 
them  freel}'  in  typhus  fe^'er. 

I  have  long  held  the  opinion,  which  I  find  agrees  with  that  of  the 
majority  of  physicians  at  the  present  time,  that  the  principal  object  aimed 
at  and  the  value  of  the  bath  treatment  lie  not  so  much  in  the  reduction 
of  the  temperature  as  in  the  favorable  effect  produced  on  the  entire 
symptom-complex  of  the  fever,  particularly  on  certain  vital  centers  that 
are  especially  implicated — namely,  the  respiratory  and  circulatory  centers. 
The  truth  of  this  appears  more  forcibly  in  typhus  fever  than  in  any 
other  febrile  disease.  Whereas  I  frequently  observed  an  exceedingly 
slight  and  very  temporary  influence  on  the  temperature,  the  effect  of  the 
baths  on  the  cerebral  functions  and  on  the  respiratory  and  circulatory 
organs  was  always  so  marked  and  persistent  that  I  do  not  believe  typhus 
fever  can  possibly  be  treated  without  frequent  regular  baths. 

The  method  to  be  jnirsued  in  the  bath  treatment  must  be  strictly 
regulated  according  to  the  individual  case.  I  have  already  dealt  with 
this  method  at  some  length  in  the  section  on  Typhoid  Fever,'  to  which 
I  refer  the  reader  for  further  details.  I  will  only  say  that  in  typhus,  as 
in  typhoid  fever,  I  never  use  cold  baths  except  under  special  circum- 
stances, and  usually  prefer  Ziemssen's  method  of  gradually  reducing  the 
temperature  of  the  bath.  I  place  the  patient  in  a  bath  of  24°  to  26°, 
and  gradually  cool  the  water  to  20°  or  18°,  rarely  lower.  A  cold, 
dam]>  cloth  or  an  ice-cap  is  applied  to  the  patient's  head  during  the  bath. 

Except  in  cases  of  extreme  debility  or  with  some  local  contraindi- 
cating  affection  it  is  a  good  practice,  in  stuporous  and  comatose  patients, 
1  See  Tijpho'id  Fever,  p.  450. 


TREATMENT.  021 

to  give  a  cold  douche  over  the  head  and  trunk,  either  at  intervals  (hiring 
the  bath  or  at  the  end  of  the  bath.  Again,  however,  1  use  cold  water  (jr 
even  iced  water  only  in  special  cases,  contenting  myself  with  Avater  at  a 
temperature  of  18°,  gradually  reduced  to  10°,  although  others,  on 
Currie's  recommendation,  have  advised  the  use  of  ice-water  as  a  routine 
practice. 

The  frequency  of  the  baths  should  depend  not  alone  or  even  chiefly 
on  the  body-temperature,  as  I  must  again  emphasize,  but  on  the  general 
condition,  and  particularly  on  the  condition  of  the  central  nervous  system, 
the  pulse,  and  the  respiration.  As  these  symptoms  are  likely  to  be  so 
much  more  obstinate  and  severe  in  typhus,  a  greater  number  of  baths 
will,  as  a  rule,  be  necessary  than  in  typhoid  fever. 

When  the  facilities  are  limited,  as  in  private  practice,  where  it  is  not 
always  possible  to  give  a  full  bath,  it  may  be  advisable  to  use,  instead, 
lukewarm  and  cool  sponging  combined  with  douches.  Personally  I 
have  very  little  experience  in  regard  to  their  efficacy,  but  on  general 
principles  I  do  not  believe  their  value  can  be  as  great  as  that  of  a  reg- 
ular course  of  bathing. 

Cold  douches  in  an  empty  bath-tub,  as  first  recommended  by  Currie 
and  after  him  employed  by  many  physicians,  some  of  whom  carried  it 
to  an  unreasonable  extent,  I  believe  to  be  a  much  inferior  method.  I 
employ  it  only  in  conditions  of  deep  coma  and  stupor,  or  occasionally  in 
marked  cataleptic  conditions,  providing  they  are  not  complicated  by  a 
subnormal  temperature.  My  experience  is  strongly  against  the  advisa- 
bility of  employing  it  in  conditions  of  marked  excitement. 

In  place  of  cold  baths  Hermann,  on  the  strength  of  his  experiences 
during  the  Petersburg  epidemic  of  1874  and  1875,  advocates  the  use 
of  protracted  lukewarm  baths.  His  ultimate  results — he  had  a  mor- 
tality of  16.6  per  cent. — are  not  very  encouraging. 

In  a  few  instances  I  have  seen  favorable  results,  especially  as  regards 
the  sedative  effect,  from  baths  of  this  kind  combined  with  cold  compresses 
or  an  ice-bag  to  the  head.  I  should  advise  that  the  method  be  tested 
carefully  in  future  epidemics,  especially  as  certain  modem  authors  in 
Germany  (Riess,  Unverricht,  and  Eichhorst)  have  warmly  recommended 
it  in  the  treatment  of  typhoid  fever. 

In  accordance  with  the  then  accepted  principles  of  therapeutics  I 
made  a  very  extensive  use  of  antipyretic  remedies  during  the  years 
from  1876  to  1878,  without,  however,  any  marked  result. 

Now  that  opinions  on  the  treatment  of  fever  have  undergone  so 
marked  a  change,  and,  as  has  been  repeatedly  stated,  the  advantage  of 
reducing  the  temperature  alone  is  accounted  of  much  less  importance 


622  TYPHUS  FEVER. 

than  lormerly,  I  am  iuclinecl  to  make  but  a  very  limited  use  of  such 
remedies,  and  would  reeommend  great  eare  in  their  selection.  This 
precaution  is  all  the  more  necessary  as  typhus  lever  patients  ai"e  much 
more  liable  to  be  attacked  by  sudden  hciirt-tailure  than  are  patients 
suffering  from  typhoid  fever. 

The  use  of  salicylic  acid,  sodium  salicylate,  kairin,  thallin,  and  anti- 
febrin  should  be  abandoned  altogether,  on  account  of  their  marked 
effect  on  the  heart.  Quinin,  antipyrin,  phenaeetin,  and  lactoj^henin 
may  be  nsed  in  certain  ciises,  according  to  the  j)rinciples  laid  do\vn  for 
the  trciitment  of  typhoid  fever. ^ 

Of  all  these  remedies,  lactophenin  is  the  one  I  am  most  inclined  to 
recommend,  and  I  have  recently  had  considerable  experience  with  it.  It 
is  practically  without  any  injurious  effect  on  the  heart  and  respiration, 
and,  in  addition  to  its  marked  antipyretic  action,  it  is  especially  useful 
for  allaying  excitement,  delirium,  and  insomnia. 

Other  remedies  hardly  come  into  consideration  in  an  ordinary  case 
of  typhus  fever.  In  private  practice  and  for  hospital  patients  who 
are  fond  of  taking  medicine,  the  usual  hydrochloric  acid  mixture  or  a 
decoction  of  quinin  w^ith  hydrochloric  acid  may  be  prescribed. 

TREATMENT   OF   SPECIAL   CONDITIONS   AND  ORGANIC 
CHANGES. 

In  speaking  of  the  events  and  conditions  that  may  call  for  especial 
therapeutic  intervention  in  the  course  of  typhus  fever  I  may  mention 
particularly  weakness  of  the  circulation,  cardiac  and  vaso- 
motor palsy,  and  collapse  in  general. 

In  a  disease  which  is  relatively  so  short  in  duration  and  so  severe  in 
its  symptoms,  where  the  crisis  may  bo  expected  at  a  definite  period,  the 
patient's  life  may  depend  on  beginning  a  rational  treatment  to  combat 
impending  collapse  at  the  proper  moment,  and  gradually  increasing  its 
force.  Everything  may  depend  on  keeping  the  patient  alive  until 
the  fifteenth  or  seventeenth  day,  when  the  crisis  and  a  spontaneous 
change  for  the  better  may  be  expected. 

Although  stimulating  remedies  should  be  strictly  withheld  in  any 
uncomplicated  case,  they  should  be  employed  unhesitatingly  to  their 
fullest  extent  at  the  first  sign  of  impending  fiiilure  of  the  circulation. 

Among  stimulating  remedies  the  first  place  is  accorded  to  alcoholic 
beverages,  although  their  manner  of  action  may  not  be  quite  fully  under- 
stood. At  the  first  sign  of  weakness,  old  Rhine  wine,  Bordeaux,  or 
Burgundy,  according  to  the  individual's  circumstances,  should  be  given  ; 

^  Typhoid  Fever,  p.  461. 


TEEA  TMENT.  623 

if  more  active  stimulants  are  required,  port,  heavy  Hungarian  wines, 
sherry,  or  champagne.  Patients  of  the  poorer  classes  may  be  given 
brandy,  either  with  or  without  water.  If  cyanosis  is  present,  and  the 
extremities  are  cold  and  the  tcsmperature  is  subnormal  or  the  ])atient  is  in 
collapse,  grog,  mulled  wine,  or  cognac  in  strong  black  coifee  or  tea  may 
be  used  with  advantage. 

I  particularly  recommend  the  use  of  alcohol  in  the  form  of  tlie  well- 
known  Stokes'  mixture,  on  account  of  the  ease  with  which  the  dose  may  be 
regulated,  and  because,  being  in  the  form  of  a  medicine,  it  may  be  given 
without  the  patient's  knowledge.  The  formula  in  use  in  my  clinic  is  as 
follows : 

R.     Spirit,  vin.  cognac,  50.0 

Vitell.  ov.,  No.  1 

Syr.  cinnamom.,  25.0 

Aquae  dest.,  150.0. 

M.    Sig. — One  or  two  tablespoonfuls  every  two  hours. 

Occasionally  I  add  tinct.  valer.  aether.,  3.0  to  5.0,  as  a  nerve  tonic.  If  the 
patient  cannot  swallow  or  absolutely  refuses  to  take  alcohol,  it  may  be 
administered  in  a  nutritive  enema  of  the  following  formula  : 

R.     Spirit,  vin.  cognac,  40.0 

Tinct.  valer.  cether.,  5.0 

Yitell.  ov.,  No.  1 

Muc.  gum  arab.,  20.0 

Aqua,  q.  s.  ad     180.0. 

M.    Sig. — To  be  given  as  enema  and  repeated  three  times. 

To  combat  the  collapse  I  prefer  camphor  to  caffein.  Both  are  admin- 
istered exclusively  in  the  form  of  hypodermic  injections,  caffein  m 
the  form  of  caffein.  natr.  salicyl.,  on  account  of  the  greater  solubility  in 
this  form. 

I  never  use  hypodermic  injections  of  ether,  as  they  are  neither  so 
quick  nor  so  lasting  in  their  effects  as  camphor,  and  are,  besides,  \ery 
painful  and  frequently  produce  abscesses  and  necrosis  of  the  fatty  tissues. 

For  the  hypodermic  injection  of  camphor  a  freshly  prepared  solution 
is  to  be  preferred  to  the  official  camphor  oil  found  in  the  stores.  I  use  a 
strong  and  a  weak  solution,  according  to  the  formulas  : 

R.     Camphor,  trit.,  1.0; 

^th.  sulph.,  ■  2.0; 

01.  oliv.  puriss.,  8.0. 

Or  as  solutio  camphori  fortius  : 

R.     Camph.  trit.,  1.0; 

01.  oliv.  puriss.,  ■  5.0. 


624  TYPHUS  FEVER. 

If  the  use  of  camphor  has  been  decided  upon,  it  should  be  given  in  gen- 
erous doses.  One  or  two  syringefuls  of  the  weaker  solution  niav  be  given 
every  one  to  three  hours,  and,  under  certain  circumstances,  the  same  amount 
of  the  stronger  may  be  similarly  administered.  >.'o  disagreeable  results 
will   be  experienceil,  and  the  effect  is  often  exceedingly  good. 

Cati'ein  is  no  less  etiicacious  than  camphor.  As  vjisomotor  paralvsis 
probably  plays  au  important  part  in  the  production  of  collapse  in  typhus 
fever,  as  it  does  in  other  infectious  diseases,  caffein,  owing  to  its  special  action 
on  the  vasomotor  system,  is  often  found  extremelv  useful. 

AVhen  the  pulse  is  very  rapid,  irregular,  and  low  iii  tension,  digitalis 
is  indicated  and  may  prove  useful.  If,  however,  the  collapse  continues, 
it  is  better  to  substitute  caffein. 

These  procedures  should,  of  course,  be  combined  with  other,  especially 
physical,  methods  of  treatment,  either  cooling  applications — as,  for 
example,  the  ice-bag  to  the  head  or  the  precordia,  and  the  use  of  the 
water  mattress,  with  or  without  changing  the  water,  and  cool  sponging — 
or  the  application  of  warmth.  In  impending  heart-failure  cold  or  even 
lukewarm  baths  mnst  be  used  with  caution.  None  but  a  bigoted  fanatic 
on  the  subject  of  hydrotherapy  will  deny  that  they  tend  to  bring  on 
collapse. 

When  the  pulse  is  thready,  the  temperature  is  subnormal,  and  the 
face  and  extremities  are  cyanotic,  much  good  may  be  accom])lished  by 
filling  the  water  mattress  with  warm  water,  by  applying  hot-water 
bottles,  by  wrapping  the  extremities  in  flannels,  and  by  the  application 
of  Leiter's  apparatus — using  warm  water — to  the  precordia. 

Nervous  Symptoms. — Among  other  symptoms  and  complications 
requiring  special  treatment  those  affecting  the  nervous  system  occupy 
the  first  place. 

The  intolerable  headache,  which  frequently  declares  itself  at  the 
beginning  of  the  disease,  requires  energetic  treatment.  A  water  pillow 
and  an  ice-cap  should  first  be  ordered,  followed  in  many  cases  by  cold 
douches  to  the  head.  These  may  be  given  almost  without  changing  the 
patient's  position,  merely  by  holding  his  head  over  the  edge  of  the  bed 
and  placing  a  vessel  under  it. 

Many  patients  find  compresses  of  cold  water,  to  which  is  added  a 
little  vinegar,  alcohol,  or  eau  de  cologne,  grateful.  Warm  compresses 
are  sometimes  soothing,  especially  in  old,  anemic,  or  very  feeble  persons. 

In  youthful,  plethoric  individuals  no  hesitation  should  be  felt  in 
applying  artificial  leeches  behind  each  ear  or  to  the  temporal  region. 

If  these  measures  fail  to  relieve  the  headache,  antipyrin,  phenacetin, 
and  lactophenin  may  be  resorted  to.  Even  opiates,  especially  hypo- 
dermic injections  of  morphin  (0.01  to  0.015   gm.  per  dose  in  adults), 


TREATMENT.  625 

may  be  given  without  the  slightest  hesitation  and  are  often  of  great 
use. 

Another  equally  important  symptom  re(iuiring  special  treatment 
is  insomnia.  If  this  continues  uninterruptedly  for  several  days,  it 
may  threaten  the  patient's  life,  and  in  any  stage  of  the  disease  a  reason- 
able amount  of  normal  sleep  exerts  a  marked  influence  on  tlie  cerebral 
centers,  which  are  often  so  profoundly  involved,  and,  through  them,  on 
the  entire  course  of  the  disease. 

The  open-air  and  bath  treatment  is  extremely  valuable  and  often 
suffices  to  overcome  the  insomnia. 

If  the  patient  is  accustomed  to  the  use  of  alcohol,  a  small  quantity 
of  beer,  either  one  of  the  darker  varieties  or  porter,  may  with  advan- 
tage be  given  in  the  evening.  Some  few  patients  are  relieved  by  bro- 
mid  or  valerian,  or  the  two  drugs  in  combination.  The  insomnia  as 
well  as  the  headache  may  require  opium  or  morphin,  and  these  drugs 
should  be  given  unhesitatingly.  I  strongly  object  to  chloral  on  account 
of  the  unfavorable  effect  it  exerts  on  the  circulation.  Some  of  the 
newer  hypnotics,  which  have  been  found  so  useful  in  various  conditions, 
will  require  testing  in  future  epidemics  of  typhus  fever. 

In  the  treatment  of  the  delirium  hydrotherapeutic  procedures  are, 
of  course,  the  most  efficacious,  and  their  skilful  use,  with  due  regard  to 
individual  peculiarities,  may  often  prevent  the  occurrence  of  violent 
excitement. 

If,  however,  in  spite  of  their  use,  violent  excitement  and  delirium 
develop,  lukewarm  packs  or  lukewarm  baths  should  be  used  in  addi- 
tion to  the  application  of  the  ice-bag  or  cold  compresses  to  the  head. 
The  lukewarm  packs  or  baths  are  to  be  preferred  to  cold  douches  or 
cold  tub-baths. 

The  drugs  to  be  preferred  in  combating  this  symptom  include  bro- 
mid,  valerian,  and  the  opiates,  even  morphin.  I  am  in  the  habit  of 
giving  bromid  and  opium  together  in  the  following  formula  : 

R.     Sod.  brom.,  10.0; 

Tinct.  opii  simpl.,  2.0; 

Spir.  vin.  cog.,  10.0; 

AquEe  menth.,  q.  s.  200.0. 

The  psychic  treatment  is  of  the  greatest  importance  in  violent 
delirium.  A  great  deal  may  depend  on  the  manner  of  physician  and 
attendants.  The  room  and  its  immediate  surroundings  should  be  abso- 
lutely quiet,  and  no  one  but  those  whose  presence  is  absolutely  required 
should  be  allowed  to  come  near  the  patient.     He  should  not  be  spoken 

40 


62(j  TVrilUS  FEVER. 

to  unnecessarily,  and  force  should  never  be  used  e.\('ej)t  in  extreme  cases. 
Firmness  and  a  confident  demeanor  on  tlie  part  of  hi.s  attendants  give 
the  greatest  amount  of  encouragenient  to  the  patient. 

If  deep  coma  and  stupor  develop,  stimulants  may  be  required. 
Under  such  conditions  cold  douches  in  a  lukewarm  bath  or  in  an  empty 
bath-tub  may  be  useful.  The  importance  of  careful  attention  to  the 
urinary  secretion,  and  the  free  use  of  tiie  catheter,  if  necessary  to 
combat  ischuria  and  overfilling  of  the  bladder,  cannot  be  too  strongly 
insisted   upon,  particularly   in  the  case  of  a  stuporous  patient. 

The  vomiting"  that  often  accompanies  the  headache  and  is  evidently 
of  cerebral  origin  will  rei[uirc  the  treatment  aj^propriate  to  that  condi- 
tion. Small  pieces  of  ice  and  the  application  of  the  ice-bag  to  the 
epigastric  region  will  be  found  of  value.  I  have  often  obtained  good 
results  from  the  use  of  aqua  amygdala-  amarie. 

To  relieve  the  troublesome  hyperesthesia  of  the  skin  and  nuiscles 
and  the  obstinate  pains  in  the  fingers,  toes,  and  soles  of  the  feet,  which 
are  particularly  common  during  the  initial  stage  and  again  during  the 
period  of  defervescence,  cool  or  lukewarm  Preissnitz  bandages  should  be 
tried.  If  drugs  are  resorted  to,  chloroform  liniment  or  menthol  should 
be  preferred,  the  latter  either  in  a  solution  of  olive  oil  or,  what  I 
believe  to  be  even  better,  in  the  form  of  a  paste : 

R.   Menthol, 

Amyl,  da    2.0 ; 

Vaselin.  puriss.,  50.0. 

M.     Sig. — Spread  thickly  on  a  piece  of  lint  and  apply. 

The  respiratory  organs  may  require  treatment  in  various  ways. 

The  greatest  attention  should  be  paid  to  the  condition  of  the  nose, 
the  nasopharynx,  and  the  larjaix. 

Attendants  should  be  instructed  to  pay  special  attention  to  the  care 
of  the  nose  and  mouth.  Irrigation  of  the  nose  with  weak  salt  solution 
or  some  disinfecting  solution  may  occasionally  be  necessary'. 

For  the  milder  affections  of  the  throat  and  larynx  the  usual  gargles 
are  quite  appropriate.  If  the  voice  begins  to  change  and  hoarseness 
develops,  the  greatest  vigilance  is  necessary.  The  great  liability  to 
severe  and  rapidly  progressing  changes  in  the  larynx  in  typhus  fever 
and  the  sudden  development  of  edema  of  the  glottis,  often  leading  to 
asphyxia,  must  always  be  borne  in  mind.  Under  such  cireimistances 
the  patient,  especially  if  he  is  unconscious,  should  be  watched  day  and 
night  by  a  responsible  person  to  ascertain  the  proper  moment  for  trache- 
otomy. 


TREATMENT.  627 

Tracheobroncliitis  is  one  of  the  oommonest  (symptoms  of  trie  disease 
and  requires  no  special  treatment.  It  is  lilcely  to  he  followed  hy  hypo- 
static congestion  of  the  lungs,  which  event  may  occasionally  be  pre- 
vented by  strengthening  the  heart  and  frequently  changing  the  position 
of  the  patient. 

The  digestive  organs  do  not,  as  a  rule,  require  treatment. 
During  the  height  of  the  disease  and  during  convalescence  obstinate 
constipation  sometimes  occurs  and  may  be  treated  l)y  means  of  enemata, 
mild  abdominal  massage,  and,  in  contradistinction  to  typhoid  fever,  by 
the  administration  of  cathartics. 

Diarrhea  and  meteorism  rarely  require  therapeutic  intervention. 
Meteorism  is  usually  a  most  ominous  symptom,  and,  when  it  is  present, 
all  remedies  are  valueless. 

The  changes  in  the  skin  that  frequently  occur  during  the  period 
of  convalescence  are  to  be  treated  exactly  as  in  typhoid  fever. 

As  regards  the  development  of  bed-sores,  the  greatest  watchfulness 
is  necessary,  for  the  patients  are  usually  profoundly  prostrated  and 
unconscious  from  the  beginning.  Great  care  is  necessary  not  only  to 
keep  the  bedding  clean  and  smooth,  but  also  to  subject  the  body  to  care- 
ful daily  examination.  It  has  been  shown  how  quickly  the  most 
extensive  subcutaneous  bed-sores,  which  at  first  are  not  noticeable, 
may  develop. 

The  treatment  during  convalescence,  if  no  complications 
develop,  is  simpler  than  in  any  other  acute  infectious  disease. 

After  the  end  of  the  febrile  period  the  patients,  as  a  rule,  recover 
very  rapidly,  and  the  physician  is  more  often  called  upon  to  restrain 
and  admonish  than  to  encourage. 

The  appetite,  when  it  returns,  may  be  gratified  without  any  special 
restrictions,  as  has  already  been  shown.  I  refer  the  reader  to  the  direc- 
tions previously  given  as  to  diet. 

The  nervous  system  and  the  heart  call  for  more  careful  attention 
at  this  time  than  do  the  digestive  organs.  In  many  convalescents  there 
is  a  persistent  nervous  irritability  or  a  condition  of  depression,  with 
marked  deterioration  of  the  intellect  and  memory.  Such  conditions 
require  complete  rest  and  freedom  from  exertion.  Too  early  mental 
effort  or  excitement,  whether  pleasurable  or  the  reverse,  are  likely  to 
retard  recovery. 

A  prolonged  period  of  rest  is  necessary,  especially  if,  after  defer^'es- 
cence,  the  pulse  continues  slow  and  weak.  Under  such  conditions  the 
patient  should  be  kept  in  bed  until  the  symptoms  have  improved,  after 


628  TYPHUS  FEVER. 

Avliic-h  he  may  be  allowed  to  get  up  for  an  hour  at  a  time.     Any  negleet 
may  lead  to  syneope  and  directly  endanger  the  patient's  life. 

After  a  severe  attiick  of  typhus  fever,  a  period  of  recuperation, 
protracted  according  to  the  individual's  needs,  should  be  insisted  upon 
before  allowing  him  to  resume  his  usual  activity.  If  the  patient's  cir- 
cumstances permit,  a  sojourn  in  a  southern  climate,  in  the  mountains, 
or  at  the  seashore  may  be  prescribed.  For  poon-r  patients  a  prolonged 
stiiv  in  the  hospital  or  in  a  convalescent's  home  in  the  country  is 
advisable. 


LITERATURE. 


Jacobus  de  Partibus,  Commentar.  ad  Avicenn.,  1498. 

Frascatori,  Opera  omnia.     De  contagionibus  et  morbis  contagiosis.     Yenet.,  1555. 
Massa,  De  febr.  pestil.  cum  petechiis.     Venet.,  1556.     Haller's  Bibl.  med.  pract.  I. 
Andr.  Gratioli,  Commentar.  de  Peste.     Venet.,  1556. 
Lebenwald,  Chronik  aller  denkwiirdigen  Pesten.     Niirnberg,  1615. 
Huxham,  Observ.  de  aere  et  morbis  epidemicis.     London,  1752. 
—  Essay  on  Fevers,  Ilnd  Ed.     London,  1757. 
Hasenohrl,  Histor.  medic,  morbi  epidemici  etc.     Vindob.,  1763. 
Strack,  Observ.  med.  de  morbo  cum  petechiis.     Carlsruhe,  1786. 
Eennebaum,   Histor.  morb.   contag.   anni  1793  et  1794  a  Francogallis  captivis  Culm- 

bacium  delati.     Erlangen,  1796. 
Schafer,  Ueber  das  in  und  um  Eegensburg  1793  herrschende  Nervenfieber.     Erlangen, 

1796. 
Currie,  Medical  Reports  on  the  Effects  of  Water  as  a  Remedy  in  Fever.     London, 

1797. 
J.  Hartmann,  Der  ansteckende  Typhus.     Med.  chirurg.  Zeitung,  Nr.  45,  1807. 
A.  Fr.  Hecker,  Ueber  die  Nervenfieber,  welche  in  Berlin  1807  herrschten.     Erfurt, 

1809. 
v.   Hildenbrand,   Ueber  den  ansteckenden  Typhus,    nebst  einigen  Winken  zur  Be- 

schrankung  oder  ganzlichen  Tilgung  der  Kriegspest  und  mehrerer  anderer  Men- 

schenseuchen.     Wien,  1810.     (A  book  for  its  time  remarkably  objective,  and 

even  to-day  still  well  worth  reading. ) 
Wedemeyer,  De  febr.  petechial.     Gottingen,  1812. 
Hartmann,  Theorie  des  ansteckenden  Typhus.     Wien,  1812. 
Rasori,  Storia  della  febr.  petech.  de  Genova  1799—1800.     Milano,  1813. 
Hufeland,  Ueber  die  Kriegspest.     Berlin,  1814. 

Ackermann,  Von  der  Natur  des  ansteckenden  Typhus.     Heidelberg,  1814. 
Horn,  Erfahrungen  iiber  die  ansteckenden  Nerven-  und  Lazarethfieber.    2.  Aufl.     Ber- 
lin, 1814. 
Wolff,   Bemerkungen  iiber  die   Krankheiten,   welche   im   Jahre  1813   in  Warschau 

herrschten,  besonders  iiber  den  ansteckenden  Typhus.     Hufel.  Journ.,  1814. 
Renard,  Beitrage  zur  Geschichte  der  Hirnentziindung  und  des  ansteckenden  Typhus. 

Hufel.  Journ.,  1815. 
Reuss,  Identitat  des  Fleckfiebers  mit  der  oriental.  Pest.     Niirnberg,  1815. 
Armstrong,  A  Pract.  Illustr.  of  Typhus  Fever.     London,  1819. 
R.  Jackson,  A  Sketch  of  the  History  of  Contagious  Fever.     London,  1819. 
Barker  and  Cheyne,  An  Account  of  the  Fever  Latelv  Epidemical  in  Ireland.    London. 

1821. 
Marsh,   Observ.  on  the  Origin  and  Latent  Periods  of  Fevers.     Dublin  Hosp.   Rep., 

1827,  Vol.  4. 
Corrigan,  On  the  Epidemic  Fever  of  Ireland.     Lancet,  1829  and  1830. 
Gaultier  de  Glaubry,   De  I'identite  du   typhus  et  de  la  fievre  typhoide.     Mem.    de 

I'Acad.  de  med.,   T.  VII,   1835. 
Pfeuffer,  Beitrage  zur  Geschichte  des  Petechialtyphus.     Bamberg,  1831. 

629 


630  LITERATURE. 

Perry,  Letter  on  Typhus  Fever.     Dublin  Journ.  of  Med.  Sc,  1836. 

Gerhard  and  Peuiiok,  On  the  Typhus  Fever  which  occurred  at  Pliihidelphia  in  1836. 

Amer.  Journ.  of  Med.  Science,  Vol.  19  and  20,  1837. 
Thomson,  A  Statistical  Inquiry  into  Fever.     Edinb.  J^Durn.,  Vol.  50,  1838. 
Graves,  On  the  State  of  the  Pupil  in  Typhus  and  the  Use  of  Belladonna  in  Certain 

Cases  of  Fever.     Dubl.  Journ.,   1838. 
Valleix,  Du  "Typhus  fever"  et  de  la  Mevre  typhoide  d'Angleterre.     Arch.  gen.  de 

nied.,  1839. 
Poupell,  Treatise  on  Typhus  Fever.     London,  1839. 
Anderson,  Observ.  on  Typhus.     Glasgow,  1840. 
Christison,  Art.  Continued  Fever  in  Twedie,  Syst.  of  Pract.  Med.,  Vol.  I.,  London, 

1840. 
Landouzy,  Sur  1 'epidemic  de  typhus  carceral  qui  a  regne  a  Keiins  en    1839 — 1840. 

Arch.  gen.  de  med.,  1842. 
Kennedy,  On  the  Connex.  Between  Famine  and  Fever  in  Ireland  etc.     Dublin,  1847. 
Stokes   and  Cusak,   On    the   Mortality  of  Med.  Practitioners   in   Ireland.     Dublin, 

Journ.  of  Med.  Sc,  1847,  1848. 
Omerod,  Clin.  Observ.  on  Continued  Fever  at  St.  Bartholomew's  Hosp.    London,  1848. 
Graves,  Clin.  Lect.  on  the  Practice  of  Medicine.  II.  Ed.     Dublin,  1848. 
Virchow,    Mittheilungen    iiber  die    in   Oberschlesien   herrschende    Typhusepidemie. 

Yirch.  u.   Eeinh.   Archiv,   Bd.   II,   1849. 
Stich,  Zur  patholog.  Anatomic  des  oberschles.  Typhus.     Ebenda,  S.  323. 
V.  Bcirensprung,  Ueber  den  Typhus  in  Oberschlesien.     Haeser's  Arch.  X,  4,  1849. 
Virchow,  Kritisches  iiber  den  oberschles.  Typhus.     Virch.  Arch.,  Bd.  Ill,  1849. 
Suchanek,  Mittheil.  iiber  die  Typhusepidemie  im  Teschener  Kreise.     Prager  Viertel- 

jahrschr.,  Bd.  21,  1849.. 
Schiitz,  Ueber  Typhus  exanthematicus,  beobachtet  in  den  "Wintermonaten  des  Jahres 

1847,  1848. 

—  Ebenda,  Bd.  22,  1849. 

Finger,  Die  wJihrend  der  Jahre  1846 — 1848  im  Prager  allg.  Krankenhause  beobach- 
teten  Epidemien,  1846—1848. 

—  Ebenda,  Bd.  23,  1849. 

Jenner,  Typhus  and  Typhoid.     Edinb.   Monthly  Journ.  of  Med.  Science,  Vols.  IX 

and  X,  1849—1850. 
Christioson,   On  the  Distribution  of  Fever   Patients  in  a  Hospital.     Monthly  Med. 

Journ.,  1850. 
Flint,   Clinical   Keports   on   Continued   Fevers  Based  on  an  Analysis  of  164  Cases. 

Buffalo,   1852. 
Lindwurm,  Der  Ty^jhus  in  Irland,  beobachtet  im  Sommer  1852.     Erlangen,  1853. 
Forget,  Preuves  cliniques  de  la  non-identite  du  typhus  et  de  la  fievre  typhoide.     Gaz. 

med.  de  Paris,  1854. 
Virchow,  Die  Noth  im  Spessart.     Wiirzburger  Verhandl.,  Bd.  Ill,  S.  105. 

—  Die  Hungerepidemie  in  Unterfranken  etc.     Ebenda,  S.  161.     (Both  articles  also 

in  Ges.  Abhandl.  aus  d.  Geb.  d.  offentl.  Med.  u.  Seuchenlehre. ) 
Bartlett,  The  Fevers  of  the  United  States,  4th  Ed.  Philadelphia,  1856. 
Jaquot,  Du  typhus  de  I'armee  d'Orient.     Paris,  1856. 
Peacock,  On  the  Varieties  of  Continued  Fever  and  their  Discrimination.    Med.  Times, 

1856. 
Godelier,  Eesume  d'une  memoire  sur  le  typhus,  observe  en  Val-de-Grace  etc.     Gaz 

des  hop.,  Juli,  1856. 
Mayer   Das  Typhusexanthem  etc.     Wochenblatt  der  Wiener  Aerzte,  1856. 
Merentie,  Kech.  clin.  et  anatom.  surquelques  points  de  1' hist,  du  typhus.    These,  Paris, 

1857. 


LITERA  TUJtK.  6^1 

Murchison,  History  of  the  Distinction  of  Typlius  and  'JVphoid  Fever.     Med.  Times, 

1857. 
Bryce,  England  and  France  before  Sebastopol,  etc.      London,  1857. 
Theuerkauf,  Typh.  exanthemat.  in  Gottingen  1856/57.     Virch.  Arch.,  Bd.  43. 
Wunderlich,  Ueber  den  Normalverlauf  einiger  typitcher  Krankheitsformen.     Arch.  f. 

physiolog.  Heilkunde,  1858. 
Euhle,  Anatom.  Mittheil.  iiberTyph.  exanthemat.   Giinsb.  med.  Zeitsch.  1858  u.  Greifs- 

wald.  med.  Beitr.,  Bd.  II. 
Murchison,  On  the  Classification  and  Nomenclature  of  Continued  Fevers.    Edinb.  Med. 

Journ.,  Oct.,  1858. 
Barallier,  Du  typhus  epidemique  a  Toulon.     Paris,  1861. 
Schnepp,  Des  fievres  typhiques  et  de  I'apparition  du  typh.  exanthemat.  en  Iilgypte. 

Un.  med.,  Oct.,  1861. 
Cazalas,  Examen  theorique  et  pratique  de  la  question  relative  a  la  doctrine  de  I'idon- 

tite  ou  de  la  non-identite  du  typhus  de  la  tievre  typhoide.    Un  med.,  1861. 
Kuhle,   DiflFerentielle  Diagnose  des  exanthem.  vom  Abdominaltyphus.     Ber.  d.  36. 

Naturforsch.-Yers.,  1861. 
Griesinger,  Ueber  Fleckfieber  etc.     Arch.  d.  Heilkunde,  Bd.  II,  1861. 
—  Acute  Infectionskrankheiten  :  Abschn.  Fleckfieber.  Virch.  Handb.  d.  spec.  Pathol. 

u.  Therap.,  2.  Aufl.,  1864. 
Wunderlich,  Beitrage  zur  Beurtheil.  der  typhos.  Kranken  mit  Hilfe  der  Warmemes- 

sung.     Arch,  fiir  phys.  Heilk.,  1861. 
Duncan,  On  the  Introduction  of  Fever  into  Liverpool,  etc.     Med.  Times,  1862, 
Gourrier,  Eelat.  d'une  epidem.  du  typhus  observe  a  Toulon  1864.     These  Montpellier, 

1866. 
Murchison,  Die  typhoiden  Krankheiten.     Uebers.  von  Ziilzer.  Berlin,  1867.      (Very 

complete  collection  of  the  literature,  especially  of  the  older  English  and  French 

works. ) 
Eosenstein,  Mittheilungen  iiber  das  Fleckfieber.    Virch.  Arch.,  Bd.  43,  1868. 
v.  Treskow,  Vorl.  Mittheil.  iiber  Vork.  d.  Typh.  exanthem.  etc.  Berl.  klin.  Wochenschr., 

Nr.  7  u.  8,  1868. 
Naunyn,  Bericht  iiber  den  exanthem.  Typhus  in  Ostpreussen.   Berl.  klin.  Wochenschr., 

Nr.  22,  1868. 
Schieferdecker,  Verhandl.  der  Berl.  med.  Ges.    Berl.  klin.  Wochenschr.,  Nr.  28,  1868. 
Becher,  Mittheilungen  ausderTyphusepidemiein  Ostpreussen.  Berl.  klin.  Wochenschr., 

Nr.  49,  50  u.  51,  1868.  *" 

Mosler,  Erfahi-ungen  iiber  die  Behandlung  des  Typh.  exanthemat.  etc.     Greifswald, 

1868. 
Varrentrapp,  Die  Fleckfieberepidemie  in  Frankfurt  a.  M.    Correspondenzblatt  fiir  die 

mittelrhein.  Aerzte,  Nr.  10  u.  11,  1868. 
Yirchow,  Ueber  den  Hungertyphus  und  einige  verwandte  Krankheitsformen.    Berlin, 

1868.  (Virch.  ges.  Abhandl.  aus  d.  Geb.  d.  offentl.  Med.  u.  Seuchenlehre,  S.  483.) 
Wegener,  Zur  Pathol,  u.  Therap.  des  Typh.  exanthemat.  Jahrb.  f.  Kinderheilk. ,  1868. 
Vital,  Le  typhus  dans  la  prov.  de  Constantine  en  1866.    Eec.  des  mem.  de  med.milit., 

1869. 
Kanzow,  Der  exanthemat.  Typhus  im  ostpreuss.  Eeg.-Bez.  Gumbinnen  vrahrend  des 

Nothstandes  im  Jahre  1868.     Potsdam,  1869. 
Gratzer,  Statistik  der  Epidemie  von  Typh.  exanthemat.  in  Breslau  i.  d.  Jahren  1868 

u.  1869.    Deutsch.  Arch.  f.  klin."  Med.,  Bd.  VII. 
Lebert,  Aetiologie  und  Statistik  des  Eiickfallfiebers  und  des  Flecktyphus  in  Breslau 

i.  d.  Jahren  1868  und  1869.    Deutsch.  Arch.  f.  klin.  Med.,  H.  3,  4  u.  5,  Bd.  VII. 
V.  Pastau,  Statist.  Bericht  iiber  das  Allerheiligenhospital  Breslau,  1870.     (S.  105  ff.) 
Passauer,  Ueber  den  exanthemat.  Typhus  in  klin.  und  sanitatspoliz.  Beziehung.   Nach 


632  LITKIIA  TURK. 

Beobaehtungen  wahrend  der  ostpreuss.  Typhusepidomie  i.  d.  Jahren  1868  u.1869. 

Erlangen,  1870. 
Perrier,  Effets  de  la  inisere  et  typhus  diius  la  piuvince  d'Alger.     Kec.  des  mem.  de 

med.  milit.,  1870. 
Wunderlich,  TJeber  die  Diagnuse  des  Flecktyplius.     Vulkra.  Saiuml.  klin.  Vortrage, 

Nr.  21,  1871. 
Murchison,  On  the  Period  of  liicubat.  of  Typhus,  Relapsing  Fever,  etc.     St.  Thomas 

Hosp.  Rep.,  Vol.  Ill,  1871. 
Obermeier,  Die  ereten  Falle  der  Berliner  Flecktyphusepideniie  von  1873.     Berl.  klin. 

Wochenschr.,  Nr.  30  u.  31,  1873. 

—  Zur  Contiigion  des  wiederkehrenden  und  des  Flecktyphus.     Centralbl.  f.  d.  med. 

Wissensch.,  Nr.  3(3,  1873. 
Ziilzer,  Zur  Aetiologie  des  Flecktyphus.     Nach  Beobaehtungen  aus  der  Berliner  Epi- 

demie  von  1873.    Yierteljahrschr.  f.  gerichtl.  Med.,  Jan.,  S.  183,  und  Zeitschr.  f. 

prakt.  Med.,  Nr.  4,  1874. 
Behse,  Beobaehtungen  iiberTyph.  exantheniat.  und  Fobricula.    Dorpat.  mod.  Zeitschr., 

Bd.  V,  1874. 
Heitler,  Bericht  iiber  die  ini  Jahre  1875  auf  der  Klinik  und  Abtli.  des  Prof.  Lobel 

beobachteten  F;ille  von  Flecktyphus.    Wiener  mod.  Jahrb.,  1875. 
Lebert,  Flecktyphus.    v.  Ziemssen's  Handb.  d.  spec.  Path.  u.  Therap.,  "1.  Aufl.,  Bd.  II, 

1876. 
Wyss,  Fleckfieber.     Gerhart's  Handh.  der  Kindcrkrankh.,  Bd.  II,  1876. 
F.  Herrmann,  Die  Flecktyphusepidemie  von  1874  und  1875.     Petersb.  med.  Wochen- 
schr., Nr.  16,  1876. 
Martin,  Etude  sur  I'endemicite  du  typhus  dans  le  depart,  du  Finistere.     These,  Paris, 

1876. 
Kaczorowski,  Ueber  die  Epidemic  des  Typhus  exantheniat.  im  Spital  der  barmherz. 

Sohwestern  in  Posen.     Deutsche  med.  Wochenschr.,  1877. 

—  Die  kalte  Luft  als  Antipyreticum.      Ebenda,  1879. 

Oser,  Ueber  den  Typhus  exanthemat.  in  Wien.     Med.  Jahrb.,  H.  4,  1877. 

Dangy  des  Deserts,  Relations  de  repidem.  de  typh.  petechial  de  Tile  Molonc.  Arch,  de 
med.  navale,  1877. 

T.  Scheven,  Ueber  die  gegen  den  exanthemat.  Typhus  in  der  Ai-niee  zu  ergreifenden 
sanitatspoliz.  Massregeln.   Yierteljahrschr.  f.  gerichtl.  Med.,  1877. 

Gestin,  Rapport  sur  les  epidemies  de  1877.     Mem.  de  I'acad.  de  med.,  T.  32,  1878. 

Benary,  Kurzer  Bericht  iiber  die  M'ahrend  des  Jahres  1878  im  Berl.  stadt.  Baracken- 
lazareth  vorgekomm.  Fiille  von  Typhus  exanthemat.  Deutsche  med.  Wochen- 
schr., Nr.  46,  1878. 

Hartmann,  Die  bei  Typhus  exanthemat.  auftretenden  Erkrankungen  der  Hororgane. 
Arch,  der  Ohrenheilk.,  1879. 

Salomon,  Bericht  iiber  die  Berliner  Flecktyphusepidemie  im  Jahre  1879.  Inaug.-Diss., 
Berlin,  1880  und  Deutsch.  Arch.  f.  klin.  Med.,  1880.  (The  articles  of  Benary, 
Hartmann,  and  Salomon  refer  to  the  material  observed  by  me  at  the  Berl. 
stiidt.  Barackenlazareths  at  Moabit. ) 

Pistor,  Die  Flecktyphusepidemie  in  Oberschlcsien  1876 — 1877.  Vierteljahrschr.  f.  ge- 
richtl. Med.,  Bd.  29,  1,  1880. 

Goltdammer,  Ueber  die  Kost-  und  Logirhiiuser  fiir  die  armeren  Volksclassen.  Viertel- 
jahrschr. f.  gerichtl.  Med.,  Bd.  29,  2,  1880. 

Krukenberg,  Zur  Pathologic  und  Therapie  des  Typh.  exanthemat.  Deutsche  med. 
Wochenschr.,  Nr.  49—51,  1880. 

Hampeln,  Ueber  Flecktyphus.     Deutsch.  Arch,  f  klin.  Med.,  1880. 

Moritz,  Kurzer  Bericht  iiber  den  Flecktyphus  im  weibl.  Obuchowspital  1879 — 1880. 
Petersb.  med.  Wochenschr.,  Nr.  17,  1881. 


LITERATURE.  63^3 

Herrmann,   Beitrag  zur  Anwendung  warmer,    prolongirter    Biidur  im    Klecktyphus. 

Petersb.  med.  Wochensehr.,  Nr.  26,  1881. 
Janeway,  Typh.  Pever  in  New  York.     Bost.  Med.  and  Surg.  Journ.,  1881. 
Guttstadt,  Fleck-  and  Eiickfalllieber  in  Preussen.     11.  Erganz.-Hcft  zur  Zeitschr.  d. 

konigl.  preuss.  statist.  Bureaux.     Berlin,  1882. 
Michaelis,  Der  exanthemat.  Typhus  in  der  russischen  Armee  auf  dor  Balkanhalbinsel 

1877/78.    Oesterr.  militiinirztl.  Zeitsch.,  1882. 
Mott  and  Blore,  Micro-organisms  in  Typhus  Fever.     Brit.  Med.  Journ.,  Dec,  1883. 
Weiohselbaum,  Ueber  einige  seltene  Complicationen  des  Typh.  exanthemat.  in  ana- 

tom.  u.  aetiolog.  Beziehung.     Allgem.  Wiener  med.  Zeit.,  Nr.  22 — 23,  1883. 
Curschmann,  Fleckfieber.    Ziemssen's  Handb.,  Bd.  2,  3.  Aufl.,  1886. 
Mantzel,  Ueber  die  Verbreitung  des  Flecktyphus  in  Preussen  (bis  1885).     Diss.  Ber- 
lin 1887.     (Unter  Guttstadt's  Leitung  bearbeilet.) 
Janowsky,  Ueber  das  Exanthem  des  Flecktyphus.     Internat.  klin.  Bundschau,  1888. 
Seeliger,  Die  Flecktyphusepidemie  in  der  stadt.  Krankenanstalt  zu  Konigsberg  1880 

bis  1882.     Berl.  klin.  Wochensehr.,  Nr.  51  u.  52,  1888. 
Eeichsgesundheitsamt,  Veroffentlichungen   des,  Ueber  eine  Flecktyphusepidemie  in 

Magdeburg,  1888. 
Chri.stic,  A  Case  of  Typhus  Fever  Complic.  with  Hematemesis.    Glasgow  Med.  Journ., 

Dec,  1888. 
Moreau  et  Cochez,  Contribut.  a  I'etudedu  typh.  exanthemat.     Gaz.  hebd.,  Nr.  28,  1888. 
Hlawa,  Etude  sur  le  typh.  exanthemat.    Arch.  Boheme  de  med.  Ill,  1,  1889. 
Thoinot,  Le  typh.  exanthemat.  de  I'ile  Tudy.     Ann.  de  hyg.  publ.  et  de  med.  legale, 

1891. 
Mey,  Zur  Kenntniss  des  Hamoglobingehaltes  des  Blutes  beim  Typh.  exanthemat.    Diss. 

Dorpat,  1891. 
Thoinot  et  Calmette,  Note  sur  quelques  examens  de  sang  dans  le  typh.  exanthemat. 

Ann.  de  I'lnstitut  Pasteur,  1892. 
Thoinot,  Art.  Fleckfieber.     Traite  de  med.,  1892. 
Lewaschew,  Ueber  die  Mikroorganismen  des  Flecktyphus.  Deutsche  med.  Wochensehr. , 

Nr.  18,  1892. 

—  Ueber  die  Mikroparasiten  des  Flecktyphus.     Ebenda,  Nr.  34,  1892. 
Erismann,  Flecktyphus  und  Cholera.     Morbiditat  des  arztl.  Standes.     Petersb.  med. 

Wochensehr.,  1892. 
Brannan  and  Cheesman,  A  Study  of  Typhus  Fever,  etc     Med.  Kecord,  1892. 
Netter,  Etiologie  et  prophylaxe  du  typh.  exanthemat.     Union  med.,  1893. 

—  Origine  brettonne  de  1 'epidemic  tvphique  de  1892/93  en  France.     Semaine  med., 

Juni,  1893. 

—  Un  cas  de  typhus  meconnu.     See.  med.  des  hopit.,  Juni,  1893. 

—  Etiologie  et  prophylaxie  du  typh.  exanthemat.     Ebenda,  Juli,  1893. 

De  Brun,  Note  sur  le  typhe  exanthemat.  observe  a  Beyrouth  dans  les  premiers  mois 

d'annee  1893.     Bull,  de  I'Acad.,  1893. 
Combemale,  Deux  cas  de  typh.  exanthemat.  avec  hypothermie.     Gaz.  hebd.,  Nr.  30, 

1893. 

—  Soc  med.  des  hopit.,  1893. 

Lanceraux,  Sur  I'epidemie  de  typh.  exanthemat.     Bull,  de  I'acad.  de  med.,  1893. 
Proust,  Note  sur  le  typh.  exanthemat.  en  France  1893  etc.     Bull,  de  I'acad.  de  med., 
1894. 

—  Typh.  exanthemat.  au  Havre  en  1893,  etc     Paris,  1893. 

Barrault,  Gaz.  hebd.,  Nr.  35  u.  36,  1893.  —  Chantemesse,  Societe  med.  des  hopit., 
1893.  —  Dubief  et  Briihl,  Semaine  med.,  1893.  (These  works  treat  of  an  epi- 
demic which  broke  out  in  Lille  in  1893,  and  spread  from  there  to  the  prisons  of 
Paris  and  environs. ) 


634  LITERATURE. 

Kelsfli,  Traite  des  maladies  epidemiques.     Paris,  1894. 

Dubief  et  Briilil,  Contrib.  a  I'etude  anatom.-pathul.  et  bacteriolog.  du   t_vpb.  cxan- 

theniat.    Arcb.  de  nied.  expor.,  Nr.  2,  1894. 
Coinbeniale,  Le  typb.  exantbeniat.  cbez  les  vieillards.     Bull.  gen.  de  tberap.,  1894. 
—  .Des  ooniplioations  pulmon.  graves  dans  le  lypb.  exantbeniat.     Ebenda,  1894. 
Dardignac,  Le  typbus  dans  I'Oise  en  1893.     Gaz.  hebd.,  Nr.  39 — 42,  1895. 
Kichter,  Ueber  i'lecktyphixs.     Deutsche  nied.  Wocbenschr.,  Nr.  34,  1895. 
Mosler,  Flecktypbus.     Eulenberg's  Encyklopiidie,  8.  Aufl.,  1895. 
Spillniann,  Contribut.  ii  I'bistoire  du  typb.  exanthemat.   Eev.  de  med.,  Nr.  8   1895. 
Pietrusky,  Ueber  das  Auftreten  des  Fleckfiebers  in  Scblesien  und  die  zu  dessen  Ver- 

biitung  geeigneten  Massregeln.    A'iertoljabrscbr.  f.  oftentl.  Gesundbeitspfl.,  1895. 
Leonbardt,  Ueber  das  Vorkonimen  von  Fleeldiebor  und  Recurrens  in  Breslau.    Zeitscbr. 

fiir  Hygiene  und  Infect.-Krankb.,  Bd.  24,  1897. 
Filatow,  Vorlesungen   iiber  acute   Infectionskrankbeiten   iiii  Kindesalter      Aus  dem 

Russischen.    Wien,  1897. 
Netter,  Flecktypbus.     Traite  de  med.  par  Brouadel,  1898. 

MacWeeney,  Note  on  tbc  Etiology  of  Typhus  Fever.    Brit.  Med.  Journ.,  Apr.,  1898. 
Balfour  and  Porter,  A  Research  into  the  Bacteriology  of  Typhus  Fevei-.     Prelimin. 

Notice,  Edinb.  Med.  Journ.,  Nr.  2,  1899. 
Pelc,  Verbreitung  des  Flecktypbus  in   Bohnien.     Prag.  med.   Wocbenschr.,  Nr.  18, 

1899. 
Littlejohn  and  Ker,  An  Outbreak  of  Typbus  Fever.    Edinb.  Med.  Journ.,  1899. 


The  above  bibliography  is  not  intended  to  be  comprehensive.  It  includes  the 
more  important  publications  dealing  with  the  epidemiology,  and  a  number  of  others 
which  contain  some  specially  valuable  data. 

For  the  older  literature,  especially  the  English  and  French  up  to  18G5,  the  reader 
is  referred  to  the  classical  work  of  Murchison.  The  same  work  and  Hirsch's  Handbuch 
der  histor.-geograph.  Pathologie  contain  a  detailed  account  of  the  history  and  geo- 
graphic distribution  of  typhus  fever. 


INDEX. 


Abdomen,  palpation  of,  in  typhoid,  214 

in  typhoid  fever,  84 
Abscess,  cutaneous,  in  typhus,  533 
Acclimutization,  diseases,  73 
Afebrile  cases  of  typhus,  576 
Age,  influence  of,  on  typhoid  infection,  56 
Air  in  transmission  of  typhoid,  49 
Albuminuria  in  prognosis  of  typhoid,  394 

in  typhoid,  186 

in  typhus,  549 
Alcoholic  beverages  as  typhoid  prophylac- 
tics, 47 
Alcoholism,  typhoid  and,  328 

typhus  and,  relation  between,  564 
Alopecia  in  typhoid,  132 
Amaurosis  in  typhoid,  286 
Ambulatory  typhoid  fever,  305 
Anemia   in   convalescence   from   typhoid, 

367 
Angina  in  typhoid,  201 
Animal  inoculation  with  typhoid,  30 
Anthrax,  typhoid   and,   differential   diag- 
nosis, 418 

typhus  and,  difi'erential  diagnosis,  603 

with  typhoid,  327 
Anti-bodies  of  typhoid,  69 
Antipyretic  drugs  in  typhoid,  460 

methods  in  typhoid,  453 
in  typhus,  619 
Antipyrin  in  typhoid,  462 
Aorta  in  typhoid,  168 
Aphasia  in  typhoid,  274,  275 
Appetite  in  typhoid,  205 
Arteritis,  obliterating,  in  typhoid,  169 

in  typhoid,  107 

typhoid,  167 
Asiatic  cholera  with  typhoid,  325 
Ataxia  in  typhoid,  278 

Bacillueia,  112 

Bacillus  of  typhus,  chemical  nature,  482 

dissemination,  484 

entrance  into  body,  487 

microparasitic  nature  of,  488 

mode  of  action,  482 
of  transmission,  480 

nature,  482 

reaction  to  chemicals,  488 
typhosus,  acids  and,  39 

agar  cultures,  29 

animal  inoculations,  30 

bacillus  coli  and,  differentiation,  419 

biology,  26 

carriers  of,  40 

channels  of  entrance  into  bod}^,  38 
of  exit  from  body,  32 


Bacillus  typhosus,  cultivation,  28 
drying  and,  35 
effect  of  gasti'ic  juice  on,  39 
gall-stones  and,  210 
gelatin  cultures,  29 
history,  25 
in  blood,  174 

from  roseola3,  127 
in  bone-marrow,  89,  90 
in  butter,  46 
in  cadavers,  35 
in  feces,  32 

vitality,  37 
in  fetus,  61 
in  milk,  45 
in  roseolas,  175 
in  spleen,  109 
in  urine,  32 

vitality,  37 
in  water,  40 

vitality,  36 
isolation  of,  from  feces,  33 
meningitis  and,  271 
morphology,  26 
movements,  27 
pneumonia  and,  251 
potato  culture,  30 
spore-formation,  27 
staining,  28 
vitality,  34 
in  soil,  53 
Bacteriuria,  190 
Baths  in  typhus,  620 
Bed-sores  in  typhoid,  130 
in  typhus,  533 
subcutaneous,  131 
Beer  as  typhoid  prophylactic,  47 
Bile  in  typhoid,  211 

Biliary   passages    in    convalescence    fi'om 
typhoid,   375 
in  typhoid,  206,  209 

post-mortem  appearance,  103 
Bladder  changes  in  typhus,  550 

in  typhoid,  post-mortem  appearance,  112 
Blood  changes  in  typhus,  525 
from  roseolffi,  127 
in  typhoid,  170 
bacteriology,  174 
hemoglobin  in,  172 
Blood-cultures  in  diagnosis  of  typhoid.  421 
Blood-serum  of  typhoid  convalescents,  69 
Blood-vessels,  changes  in,  in  typhus,  525 

in  typhoid,  167 
Bone-marrow,  bacillus  typhosus  in,  89.  90 
Bones  in  convalescence  from  typhoid,  378 
in  typhoid,  post-mortem  appearance,  89 

635 


G3G 


INDEX. 


Brain  abscess  in  typhoid,  275 

Breasts,  inflainniation  of,  in  typhoid,  197 

Broiu'lii  ill  typhoid,  L'4.j 

j>i)St-ni(irtt'iii  appt'iiranct',  114 

smaller,  catarrh  of,  in  typhoid,  24C 
Brnm-liitis  in  abortive  typhoid,  302 

in  diaijnosis  of  typiioid,  405 

in  typhoid,  24(5 
Bronehopneunioniain  typhoid,  247 
Buiil's  theory  of  typhoid,  28 
Butter  a.s  a  earner  of  infeetion  in  typhoid, 
4(i 

Calomkl  in  intestinal  antisepsis,  441 
Canine  fever,  326 

Catarrh,  g-astro-intestinal,  typhoid  and,  6G 
CatarrinU  typiius,  557 
Cerebral  anemia,  sudden  death  from,  398 
nerves  in  typhoid.  277 
tissue  in   typhoid,  post-mortem  appear- 
ance, 120 
typhoid,  316 
Cerebromalacia,  cirouniseribed,  in  tvjiboid, 

l(i8 
Cerebrospinal  fever,  tvphoid  and.  differen- 
tiation, 269 
menino-itis  in  typhoid,  270 

ty]ihoid  and,  differentiation,  413 
typhus  and,  differential  diagnosis,  598 
Chlorids  in  urine,  reduction  of,  in  typhoid, 

186 
Cholecystitis    in    oonvaleseenee    from    ty- 
phoid, 375 
in  typhoid,  209,  467 
Cholelithiasis  following  typhoid,  210 
in  convalescence  from  tvphoid,  375 
Cholera,  Asiatic,  with  typhoid,  325 
Chorea  minor  in  typhoid,  263,  280 
Chronic  affections  and  typhus,  relation  be- 
tween, 564 
Circulatory  organs,  changes  in,  in  tvphus, 
523 
disorders  of,  in  typhoid,  403 
in  typhoid,  152 
Clapham  school,  epidemic  of  typhoid  in,  51 
Climate,   effect  of,  on    tvphoid   mortality, 

384 
Clothing  in  dis.semination  of  typhoid,  54 
Coffee  as  typhoid  prophylactic,  47 
Cold,  effect  of,  on  typhoid  infection,  64 
Conjunctivitis  in  diagnosis  of  typhoid,  406 

in  typhoid,  286 
Constitution,  effect  of,   on  tvphoid   infec- 
tion, 62 
in  typhus,  effect  of,  565 
Contagion  theory  of  typhoid,  21 
Convalescence  in  typhoid,  471 
in  typhus,  627 

period  of,  condition  of  organs  during,  570 
in  typhus,  569 
Corvza  in  diagnn.^is  of  typhoid.  406 
Cranial  nerves  in  typhoid.  277 
Crv'ptogenic      septicopyemia,    differential 

diagnosis  from  typhus,   597 
Cutaneous  abscess  in  typhus,  533 
Cystitis  in  typhoid,  112 


Decomposition  theory  of  typhoid,  20 
Diabetes  mellitus  with'  typhoid,  327 
Diarrhea  in  typhoid,  216 
Dia/.o-reaction    in    diagnosis    of    tvphoid, 
405 
in  typhoid,  I'.K) 
Diet  in  typhoid,  445 

during  convalescence,  451 
in  typhus,  616 
Digestive   organs  in    prognosis  of  typhus, 
591"" 
in  typhoid,  199,  464 

post-mortem  appearance,  90 
in  typhus,  627 
tract,  changes  in,  in  typhus,  547 
Dii)htlieria  and  tvphus,  relation  between, 
564 
with  typhoid,  325 
Drinking-water  as  a  cai'rier  of  infection  in 

typhoid,  41 
Drinks  in  typhoid,  447 
Dura  in  typhoid,  post-mortem  appearance, 

119 
Dysentery  and   typhus,  relation  between, 
564 
with  typhoid,  325 

Ear   affections   in   diagno.sis   of  typhoid, 
406 

changes  in,  in  typhus,  541 

diseases  in  typhoid,  283 

in  convalescence  from  typhoid,  377 

in  typhoid,  122,  469 
Earth  in  etiology  of  typhoid,  51 
Eberth's   bacillus,   26.     See  also    Bacillvs 

typhosus. 
Ehrlich's  diazo-reaction  in  typhoid,  190 
Eisner's  method  of  examination  of  stools, 

422 
Emissions  in  typhoid,  195 
Endocarditis  in  typhoid,  105 

ulcerative,  typhoid  and,  differentiation, 
413 
Epiglottis  in  typhoid,  113,  241 
Epistaxis  in  diagnosis  of  typhoid,  406 
Erysipelas  in  typhoid,  130 

in  typhus,  533 

with  typhoid,  324 
Esophagus  in  typhoid,  204,  206 
post-mortem  appearance,  91 
Eustachian  tube  in  typhoid,  122 
Exanthemata,    typhoid     and,    differentia- 
tion,  415 

typhus  and,  differential  diagnosis,  603 
Eye  changes  in  typhus,  540 

in  convalescence  from  typhoid,  377 

in  prognosis  of  typhus,  591 
Eyeball  in  typhoid"  286 
Eyes,  diseases  of,  in  typhoid,  285 

in  typhoid,  post-mortem  appearance,  122 

FaTJI.fi EKKR,   581 

Febris    castrensis    petechialis   of    typhus, 
587 
exanthematica  sine  exanthemate,  561 
of  typhus,  599 


INDEX, 


637 


Febris  nautica  of  typhus,  588 
nervosa  stupidu,  2U4 
versatilis,  204 
Feces,  bacillus  typhosus  in,  32 

vitality,  37 
Female    genitalia,    external,    in    typhoid, 
197 
changes  in,  in  typhus,  500 
in  typhoid,  196 
Femoral  vein  in  typhoid,  109 
Fetus,  typhoid  infection  of,  Gl 
Fibrinous  pneumonia  and  typhus,  relation 

between,   563 
Fievre  des  chiens,  326 
Furuncles  in  typhoid,  130 
in  typhus,  533 

Gall-bladder    in    convalescence     from 
typhoid,   375 
in  typhoid,  209 
Gall-stones  in  convalescence  from  typhoid, 
375 
typhoid  bacilli  and.  210 
Gangrene  in  typhoid,  167 

"spontaneous,    of    the    extremities,    in 
typhoid,  167 
of  skin  in  typhoid,  132 
Gargouillement  in  typhoid,  214 
Gastric  juice,  bacillus  typhosus  and,  39 
Generative  organs  in  typhoid,  194 
Genital   functions   in   convalescence   from 

typhoid,  378 
Genito-urinary  organs,  changes  in,  in  ty- 
phus, 548 
in  typhoid,  184 
Glanders    and   typhoid,   differential   diag- 
nosis, 418 
and  typhus,  differential  diagnosis,  603 
Ground-water  theory  of  typhoid,  52 

typhoid  fever  and,  23 
Gruber's  method  of  agglutination,  424 
Gwyn's  method  of  urine  disinfection,  436 

Hair  in  typhoid,  132 
Hamburg  typhoid  fever  epidemic,  44 
Hand  disinfection  in  typhoid,  49 
Headache  in  convalescence  from  typhoid, 
377 

in  typhoid,  260 
Heart  changes  in  typhus,  525 

in  collapse  in  typhoid,  165 

in  convalescence  from  typhoid,  373 

in  typhoid,  effect  of  toxin  upon,  395 
post-mortem  appearance,  104 

muscle  in  typhoid,  159 

paralysis    of,   sudden    death   in  typhoid 
from,  398 

softening  in  typhoid,  159 
Hemiplegia  in  typhoid,  274 
Hemoglobin  in  blood  in  typhoid,  172 

in  convalescence  from  typhoid,  867 
Hemoglobinuria  in  typhoid,  189 
Hemoi'rhagic  cases  of  typhus,  581 

phenomena  in  prognosis  of  tj'phus,  592 
Herpes  facialis  in  typhus,  582 

in  typhoid  fever,  129 


Horton-Smith   method  of  urine  examina- 
tion, 423 

Household    artif;l(!S    in    diHseniinatioti     of 
typhoid,  54 

Hydrotherapy  in  typhoid,  454 
in  typhus,  019 

Hyperpyretic  cases  of  typhus,  576 

Icterus  in  typhus,  533 
Indican  in  urine  in  typhoid,  189 
Infantile  remittent  fever,  331 
Influenza,  typhoid  and,  differentiation.  414 
Inoculation  of  animals  with  tyjjhoid,  30 
Insanity,  typhoid  and,  208 
Intestinal  antisepsis,  calomel  in,  441 
in  typhoid,  441 
hemorrhage,     217.        See     also    StcxAs, 
bloody. 
in  diagnosis  of  typhoid,  406 
in  prognosis  of  typhoid,  393 
in  typhoid,  97,  405 
perforation  in  typhoid,  460 
Intestine,  cicatrization  of,  in  typhoid,  97 
in  typhoid,  post-mortem  appearance,   91 
involution  of  medullary  swelling  of,  in 

typhoid,  94 
necrosis  of,  in  typhoid,  95 
ulcers  of,  in  typhoid,  96,  98 
Intestines  in  prognosis  of  typhoid,  392 

in  typhoid,  21 1 
Intoxications,  typhoid  and,  828 
differentiation,  414 

Jaundice  in  diagnosis  of  typhoid,  406 
in  typhoid,  206 
catarrhal,  207 
toxic,  208 
Joints  in  convalescence  from  typhoid,  378 
in  typhoid,  post-mortem  appearance,  89 

Kidney  in  prognosis  of  typhoid,  394 

in  typhoid,  194 
Kidneys,  changes  in,  in  typhus,  540 

in  typhoid,  affections  of,  470 
post-mortem  appearance,  110 

Lactation,  effect  of  typhoid  infection  on, 

61 
Lactophenin  in  typhoid,  463 
Laryngeal  symptoms  in  typhoid,  244 
Laryngotyphoid,  245 
Larynx,  changes  in,  in  typhus,  644 

in  convalescence  from  typhoid,  376 

in  typhoid,   239 

post-mortem  appearance,  113 

necrosis  of,  in  tvphoid,  243 

ulceration  of,  in  typhoid,  240,  243 
Lausen  typhoid  fever  epidemic,  43 
Leukocytes  in  diagnosis  of  typhoid,  405 

in  typhoid,  172 
Lips  in  typhoid,  199 
Liver,  abscess  of,  in  typhoid,  208 

in  convalescence  from  typhoid,  375 

in  typhoid,  206 

post-mortem  appearance,  101 
Localization  theory  of  typhoid,  23 


638 


INDEX. 


Lung,  abscess  of,  in  typhoid,  254 
gangrene  of,  in  typhoid,  255 
parenciiynia,  diseases  of,  in  typhus,  545 

Lungs,  hemorrhagic  infarction   of,   in  ty- 
phoid, 111 
hypostatic  congestion  of,  in  typhoid,  248 
in  convalescence  from  tyjilioid,  376 
in  prognosis  of  tyi)h(iid,  oHl,  '■]'X', 
in  typhoid,  pi>st-mortem  appearance,  115 
tuberculous  diseases  of,  and  typhus,  rela- 
tion between,  505 

Lymph-glands,  changes  in,  in  tyjihus,  526 

Malakia  and  typhoid  fever,  65 
typlinid  and,  ditlerentiation,  414 
with  typhoid,  326 
Malarial  fever  and  typhus,  differential  di- 
agnosis, 597 
Male  genitalia,  changes  in,  in  typhus,  550 

in  typhoid,  194 
Marasmus  in  typlidid,  2U1 
Measles  and  typhoid,  differentiation,  415 
Medulla  oblongata  in  typhoid,  276 
post-mortem  appearance,  121 
Meningeal  hemorrhage  in  typhoid,  273 
Meninges,  cerebral,  in  typhoid,  post-mor- 
tem appearance,  111) 
in  typhoid,  269 
Meningitis,  cerebrospinal,  in  typhoid,  270 
epidemic    cerebrospinal,     tj^phoid     and, 

differentiation,  269 
in  typhoid,  119,  269 

manifestation  of,  272 
tuberculous,  in  typhoid,  273 
typhoid  and,  differentiation,  412 
Meningotyphoid,  316 
Menstruation      in      convalescence      from 
typhoid,  379 
in  typhoid,   196 
Mesenteric  glands  in  typhoid,  100 
Meteorism  in  prognosis  of  typhus,  592 

in  typhoid,  212';  465 
Miliaria  crystallina  in  diagnosis  of  typhoid, 
404 
in  typhoid,  128 
in  typhus,  532 
Miliary  tuberculosis  and  typhus,  relation 

between,  563 
Milk  in  dissemination  of  typhoid,  45 

modes  of  infection  of,  46 
Mitral  insufficiency  in  typhoid,  165 
Monoplegia  in  typhoid,  276 
Morphinism,  tvphoid  and,  328 
Mortality  of  typhoid,, 384 

of  typhus,  583 
Mouth  in  typhoid,  199 
Muscles  in  convalescence  from  typhoid,  378 
in  typhoid  fever,  post-mortem   appear- 
ance, 87 
Myelitis  in  typhoid,  278 
Myocarditis  in  typhoid,  105 
history,  163" 
symptoms,  160 

Nails  in  typhoid.  132 
Nasal  cavity  in  typhoid,  113 


Nasopharynx  in  typhoid,  238 
Nausea  in  typhoid,  204 
Neck,  gangrene  of,  in  typhoid,  242 
Nephritis  in  abortive  tyjjhoid,  300 
in  prognosis  of  typhoid,  394 
in  typhoid,  lll,"l9l 
duration  of  cases,  194 
prognosis,  193 
Nephrotyphoid,  192,  319 

prognosis,  394 
Nervous  diseases,  typhoid  and,  66 
fever,  259 
stupid,  312 
versatile,   312 
system,  changes  in,  in  ty])lius,  534 
disorders  of,  in  tyjiboid,  4(i9 

in  ^on^•alescen(•(■  from  tyjjlioid,  376 
in  prognosis  of  typhus,  591 
in  typhoid,  259 

post-mortem  appearance,  118 
in  ty))hus,  512,  624 
peripheral,    in    tj'phoid,    post-mortem 

appearance,  122 
toxins  and,  in  typhoid,  265 
Neuralgia  in  typhoid,  282 
Neuritis  in  typhoid,  280 
Noma  in  typhoid,  132 

in  typhus,  533 
Nose,  changes  in,  in  typhus,  542 

in  typhoid,  238 
Neuritis,  optic,  in  typhoid,  287 
Neuroses  in  typhoid,  280 

Orchitis  in  typhoid,  194 
Osteomyelitis,  typhoid  and,  89 

differentiation,  414 
Ostitis,  typhoid  fever  and,  89 

Pancreas  in  typhoid,  post-mortem  appear- 
ance, 103 
Paralysis  agitans  in  typhoid,  280 
in  typhoid,  277 
neuritic,  in  typhoid,  281 
of  ocular  muscles  in  typhoid,  286 
spinal,  in  typhoid,  279 
Paraplegia  of  legs  in  typhoid,  281 
Paratyphlitis  in  typhoid,  236 
Paresis,  facial,  in  typhoid,  277 
Parotid  gland  in  typhoid,  202 
Parotitis  in  typhoid,  202 
Pea-soup  stools,  215 
Pericarditis  in  typhoid,  106,  163 
Perichondritic  abscess  in  typhoid,  242 
Perichondritis  in  typhoid,  113,  240 
Periostitis,  typhoid  fever  and,  89 
Peripheral  nerves  in  typhoid,  280 
Peritonitis  in  abortive  typhoid,  302 
in  prognosis  of  typhoid,  392 
in  typhoid,  225 

in  childhood,  333 
perforative,  226 
age  and,  230 
causes,  228 

character  of  opening,  228 
diagnosis,  early,  234 
frequency,  229 


INDEX. 


639 


Peritonitis,    perfomtive,    in    diagnosis    of 
typhoid,  406 
in  typlioid,  90,  98 
seat  of,  227 . 
sex  and,  230 
symptoms,  231 
time  of,  228 

treatment,  operative,  235 
Perityphlitis  in  typhoid,  236 

typhoid  and,  differentiation,  408 
Petechial  typhus,  698 
Pettenkofer's  theory  of  typhoid,  23,  52 
Peyer's  patches  in  typhoid,  93,  98 
Pfeiffer  lysogenic  action  of  immune  serum, 

424 
Pfeiffer's  phenomena,  29 
Pharynx  in  typhoid,  200 
Phenacetin  in  typhoid,  462 
Phlebitis  in  typhoid,  107,  169 
Phlegmasia  alba  dolens  in  typhoid,  169 
Pia-arachnoid    in    typhoid,     post-mortem 

appearance,  119 
Plaques  gaufrees,  96 

dures,  96 
Pleura,  diseases  of,  in  typhus,  545 
Pleurisy  in  prognosis  of  typhoid,  394 
in  typhoid,  117,  257 
differential  diagnosis,  418 
Pleurotyphoid,  318 

Pneumonia  in  prognosis  of  typhoid,  893 
in  typhoid,  115 

Eberth's  bacillus  and,  251 
fibrinous,  249 
hypostatic,  249 
lobar,  249 
staphylococcic,  252 
streptococcic,  252 
typhoid  and,  differential  diagnosis,  418 
typhus  and,  differential  diagnosis,  603 
Pneumothorax  in  typhoid,  258 
Pneumotyphoid,  115,  253,  317 

prognosis,  393 
Polyarthritis,    rheumatic,    with     typhoid, 

327 
Pregnancy  and  typhoid,  relation  of,  197 
effect  of,  on  typhoid  infection,  61 
in  typhus,  551 
Prognosis  of  typhus,  583 
Prophylaxis  of  typhus,  604 
Pseudofilaments  of  bacillus  typhosus,  26 
Psychoses  in  typhoid,  265 

prognosis,  268 
Puerperium,  effect  of,  on  typhoid  infection, 

61 
Pulmonary  embolism  in  typhoid,  sudden 
death  from,  398 
gangrene  in  typhoid,  255 
infarction  in  typhoid,  255 
tuberculosis  in  typhoid,  258 
Pulse  changes  in  typhus,  523 
dicrotic,  in  typhoid,  154 
in  typhoid,  152 

diagnostic  value,  158 
effect  of  time  of  day,  154 
in  convalescence,  157 
in  defervescent  stage,  156 


Pulse  in  typhoid    in   stage  of  suhnorrnal 
temperature,  157 

prognostic  value,  158 

rapid,  155 
Purpura  variolosa,  581,  596 
Putrefactive!  tlierjry  of  typlioid,  20 
Putrid  fever,  litnuorrliagic,  .'il.'i 
Pyemia  and  typlius,  relation  b(itw(;en,  563 
Pyuria  in  typlioid,  191 

Kecurrences  in  typhus,  551 
Red    corpuscles     in     convalescence    from 
typlioid,  367 
in  typhoid,  170 
Reflexes,  sensory,  in  typhoid,  283 
Relapses  in  typhoid,  471 

in  typhus,  551 
Relapsing  fever  and   typhoid,  differential 
diagnosis,  417 
and  typhus,  differential  diagnosis,  596 
relation  between,  563 
Renal  typhus,  580 

Respiratory  organs,  changes  in,  in  typhus, 
542 
diseases  of,  in  typhoid,  468 
in  prognosis  of  Jyphus,  591 
in  typhoid,  238 

post-mortem  appearance,  113 
in  typhus,  626 
Retinal  hemorrhages  in  typhoid,  287 
Rheumatism  and  tj'phus,  relation  between, 

564 
Roseola,  bacillus  typhosus  in,  175 
in  diseases  not  typhoid,  126 
in  typhoid,  124.    See  also  Tijphoid fever ^ 

roseola  of. 
in  typhus,  504 
Roseolse  cultures,   aid  in  diagnosis  of  ty- 
phoid, 422 
Rose-spots  in  abortive  t_yphus,  559 
Rotheln  with  typhoid,  322 

Salivary  glands  in  typhoid,  post-mortem 

appearance,  90 
Saphenous  vein  in  typhoid,  170 
Scarlatina   and   typhus,   differential  diag- 
nosis, 603 
Scarlet  fever,  typhoid  and,  differentiation, 
415 
with  typhoid,  321 
Sciatica  in  typhoid,  282 
Sclerosis,  spinal,  in  typhoid,  279 
Season,  effect  of,  on  typhoid  mortality,  384 

influence  of,  on  typhoid  infection,  73 
Septic  processes  and  typhus,  relation  be- 
tween, 563 
Septicemia  in  typhoid,  cerebrospinal  men- 
ingitis with,  273 
typhoid  and,  diflerentiation,  413 
Serum-treatment  of  typhoid,  440 
Sex,  effect  of,  on  typhoid  infection,  59 
in  tvphus,  490 
effect  of,  566 
Sick-bed  in  typhoid,  444 
Sick-room,    arrangement   of,    in   tvphoid, 
435 


640 


INDEX. 


Sick-room,  disinfection  of,  in  typhoid,  437 
Skin,  anesthesia  of,  in  typhoid,  281 
changes  in,  in  typhus,  527,  ()27 
gangrene  of,  in  typhoid,  132 
in  convak'sfence  from  typhoid,  379 
in  prognosis  of  tyj)luis,  oU2 
in  typhoid,  83,  124,  4()'.t 
in  typhus,  changes  in,  527,  627 
Social  conditions  in  typlius,  496 

state,  ett'ect  of,  on" typhoid  infection,  62 
Soil  in  etiology  of  typiioid,  51 
Special  senses,  changes  in,  in  typhus,  540 
Spinal  cord  in  typhoid,  278 

post-niortein  a)>pcarance,  121 
paralysis  in  tyi>hoid,  270 
puncture  in  uicMingitis  in  tyi)hoid,  271 
Spleen,  bacillus  tyjihosus  in,  109 
changes  in  typhus,  526 
enlargement  of,  176 
absence  of,  177 
causes,   178 
demonstration  of,  180 
early,  179 
meteorism  in,  182 
palpation  in,  181 
percussion  in,  182 
protracted,  179 
reduction  of,  179 
subsidence  of,  346,  354 
hemorrhage  in,  in  typhoid,  182 
in  diagnosis  of  typhoid,  403 
infarcts  of,  in  typhoid,  182 
in  tj-phoid,  176 
examination,  180 
post-mortem  appearance,  107 
puncture  of,  in  typhoid,  422 
Sputum,  disinfection  of,  in  ty])hoid,  437 
Stomach,  dilatation  of,  in  typhoid,  206 
diseases,  typhoid  infection  and,  66 
in  typhoid,  204 

post-mortem  appearance,  91 
Stools,  bloody,  in  tvphoid,  217 
causes^  218,  219,  221 
frequency,  220 
manifestations  of,  221 
mortality,  224 
prognosis,  224 
temperature-curves  in,  223 
in  typhoid,  214 
pea-soup,  215 
Strumitis,  typhoid,  183 
Stupid  nervous  fever,  312 
Subfebrile  cases  of  typhus,  576 
Sudamina  in  abortive  typhoid,  301 
Sweating  in  diagnosis  of  typhoid,  406 

Tache  rosee  lenticulaire,  124 

Tea  as  typhoid  ])rophylactic,  47 
in  bloody  stools  of  typhoid,  223 

Temperature   in    typhoid,  cerebral  symp- 
toms and,  264 

Temperature-curve    in    abortive   typhoid, 
294 

Thyroid  gland  in  typhoid,  183 

Thyroiditis  in  typhoid,  184 

Tongue  in  typhoid,  199 


Tongue  in  typhoid,  post-mortem   appear- 
ance, 90 
Tonsils  in  typhoid,  201 
Toxin-ty})hoid  fever,  305 
Trachea  in  typhoid,  245 

post-mortem  ajipearance,  114 
Tracheobronehitis  in  typhus,  543 
Trichinosis,  typhoid,  dillerential  diagnosis, 

418 
Trismus  in  typhoid,  264 
Tuberculosis,  acute  miliary,  typhoid  and, 
ditl'erentiatioii.  410 
pulmonary,  in  typhoid,  118 
typhoid  and,  (i'i 
Tuberculous  diseases  of  lungs  and  typhus, 

relation   between,  565 
Typhe  e])i))hysaire,  414 
Typhisation  a  petite  dose,  561 
Typiioid  baeilluria,  190 
fever,  17 

abdomeni  in,  84 

abdominal  palj>ation  in,  214 

abortive,  293 

bronchitis  in,  302 
convalescence,  302 
course  of,  299 
diagnosis,  407 
nephritis  in,  300 
peritonitis  in,  302 
relapses  in,  303 
symptoms,  301 
temperature-curve  in,  294 
abscesses  in,  130 
acclimatization  and,  73 
acute  exanthemata  and,  321 

infectious  diseases  with,  323 
advnamic,  313 
afebrile,  309 

diagnosis,  407 
affections  of  kidneys  in,  470 
after-fever  of,  359 
air  in  transmission  of,  49 
albuminuria  in,  186 
alcoholism  and,  328 
amaurosis  in,  286 
ambulatory,  305 
diagnosis,  407 
and    anthrax,    differential    diagnosis, 

418 
and  other  diseases,  relations  between, 

65 
angina  in,  201 
animal  inoculation,  30 
antijjyretic  drugs  in,  460 
antipyrin  in,  462 
aorta  in,  168 
aphasia  in,  274,  275 
appetite  in,  205 

arrangement  of  sick-room  in,  435 
arteries  in,  167 
arteritis  in,  107 
Asiatic  cholera  with,  325 
ataxia  in,  278 
ataxic,  313 
ataxo-adynamic,  313 
atypical,"  with  short,  mild  course,  293 


INDEX. 


641 


Typhoid  fever  bacillus,  26.     See  ulso  Ba- 
cillus typhosus. 
bed-sores  in,  130 
bile  in,  211 
biliary  passages  in,  200,  209 

post-mortem  appearance,  103 
bilious,  311 
bladder  in,  post-mortem   appearance, 

112 
blood  in,  170.     See  also  Blood. 
blood-vessels  in,  167 
body-temperature  in,  133 
bones  in,  post-mortem  appearance,  89 
brain  abscess  in,  275 
bronchi  in,  245 

post-mortem  appearance,  114 
bronchitis  in,  246 
bronchopneumonia  in,  247 
catalepsy  in,  267 
catarrh  of  smaller  bronchial  tubes  in, 

246 
cerebral,  316 
*  meninges   in,   post-mortem  appear- 

ance, 119 

nerves  in,  277 

tissue  in,  274 

post-mortem  appearance,  120 

vessels  in,  274 
cerebromalacia  in,  168 
cerebrospinal    fever   and,    differentia- 
tion, 269 
chlorids  of  urine  in,  186 
cholecystitis  in,  209,  467 
cholelithiasis  following,  210 
chorea  minor  in,  263,  280 
chronic  diseases  with,  327 
cicatrization  of  intestine  in,  97 
circulatory  organs  in,  152 
cleanliness  of  body  in,  444 

of  patient  in,  438 

of  physicians  and  nurses  in,  438 
clinical  investigation,  401 
clothing  in  dissemination  of,  54 
collapse  in,  heart  and,  165 
complications,  122 
conjunctivitis  in,  286 
contagion  theorj^  of,  21 
contagiousness  of,  77 
convalescence  from,  366,  471 

anemia  in,  367 

appetite  in,  374 

biliary  passages  in,  375 

bones  in,  878 

cholecystitis  in,  375 

cholelithiasis  in,  375 

course,  866 

digestive  organs  in,  374 

duration,  380 

ear  in,  377 

eye  in,  377 

gall-bladder  in,  375 

gall-stones  in,  375 

genital  functions  in,  378 

headache  in,  377 

heart  in,  373 

hemoglobin  in,  367 

41 


Typhoid  fever,  convalescence  from,  joints 
in,  378 

larynx  in,  876 

leukocytes  in,  174 

liver  in,  875 

lungs  in,  876 

mr;nstruation  in,  379 

muscles  in,  378 

nervous  system  in,  376 

pulse  in,  370 

red  corpuscles  in,  367 

skin  in,  879 

temperature  in,  140,  369 

urinary  organs  in,  878 

venous  thrombosis  in,  374 
convalescent  period,  84 
course  of,  effect  of  age  on,  330 

effect  of  constitution  on,  329 

effect  of  sex  on,  329 

variations  in,  287 
cranial  nerves  in,  277 
cutaneous  anesthesia  in,  281 
cystitis  in,  112 
dead  bodies  in,  437 
death  in,  cause  of,  388 

manner  of,  895 

sudden,  396 

time  of,  387 
decomposition  theory  of,  20 
delirium  in,  261 
delusions  in,  265 
diabetes  mellitus  with,  327 
diagnosis,  400 

age  in,  408 

bronchitis  in,  405 

chronic  disease  and,  409 

conjunctivitis  in,  406 

constitutional  abnormalities  in,  409 

coryza  in,  406 

crystalline  miliaria  in,  404 

diazo-reaction  in,  405 

differential,  410 
bacteriologic,  419 

ear  affections  in,  406 

epistaxis  in,  406 

herpetic  eruptions  in,  404 

in  stage  of  defervescence,  409 

intestinal  hemorrhage  in,  406 

jaundice  in,  406 

leukocytes  in,  405 

meteorism  in,  404 

mixed  infections  in,  408 

periqd  of  observation  in,  409 

peritonitis  in,  406 

pulse  in,  403 

relapses  in,  410 

roseolous  exanthem  in,  404 

spleen  in,  403 

stools  in,  403 

sweating  in,  406 

temperature  in,  402 

visceral  disordei^s  in,  407 
diarrhea  in,  216 
diazo-reaction  in,  190 
diet  in,  445 
digestive  oro-ans  in,  199 


642 


INDEX. 


Typhoid  fever,  digestive  organs  in,  post- 
mortem a})pearance,  90 
diphtheria  with,  325 
diseases  of  respiratory  organs  in,  468 
disinfeetion  in,  49 

of  food  in,  437 

of  linen  in,  437 

of  sick-room  in,  437 

of  sputum  in," 437 

of  water  in,  437 
disorders  of  circulatory  organs  in,  463 

of  digestive  oi-gans  in.  4(54 

of  nervous  system  in,  469 
dissemination  of,  40 

facto i-s  favoring,  55 
drinks  in,  447 

dura  in,  post-mortem  appearance,  11 
duration  of,  380 
dysentery  with,   325 
ear  diseases  in,  283 
ear  in,  469 

ears  in,  post-mortem  appearance,  122 
earth  in  etiology  of,  51 
emaciation  in,  368 
emholism  in,  169 
emissions  in,  195 
endemics  of,  76 

endocarditis  and,  differentiation,  413 
endocarditis  in,  105,  106,  164 
epidemics  of,  76 
epiglottis  in,  113,  241 
epistaxis  in,  239 
eruption  of,  124 

typhoid  reseohe  and,  127 
erj'sipelas  in,  130 
erysipelas  with,  324 
esophagus  in,  204,  206 

post-mortem  appearance,  91 
especial  varieties  of,  470 
etiology,  17 

conclusions,  77 

historic  considerations,  19 
examination  of  stools  in,  422 
exanthemata  and,  differentiation,  414 
external  appearances,  post-mortem,  86 

integument  in,  124 
eve  disorders  in,  295 
eyeball  in,  286 

eyes  in,  post-mortem  appearance,  122 
fastigium  of,  82 
fatal  termination  in,  382 
febrile  course.  133 

stage,  81 

duration,  143 
female  genitalia  in,  196 
floccitation  in,  263 
food  infection  in,  434 
fulminant,  288 

diagnosis,  406 
furuncles  in,  130 
gall-bladder  in,  209 
gangrene  in,  167 

of  neck  in,  242 

of  skin  in,  132 

spontaneous,  167 
gargouillement  in,  214 


Typhoid  fever,  gastric,  311 

gastro-intestinal  catarrh  and,  66 
generative  organs  in,  194 
geniti)-urinai'y  t)rgans  in,  184 
glaiulers,  differential  diagnosis,  418 
ground-water  and,  23 

theory,  52 
hair  in,  132 
headache  in,  260 

heart  in,  post-mortem  appearance,  104 
heart-muscle  in,  159 
hemiplegia  in,  274 
hemoglobinuria  in,  189 
hemorrhagic,  313 

diagnosis,  407 
herpetic  eruptions  in,  129 
history,  17 
home  treatment,  nurses  and  assistants 

in,  435 
hospital  infection,  63 
household  articles  in  dissemination  of, 

54 
hydrotherapy  in,  454 
hyperemia  of  intestine  in,  92 
hyjierpyretic,  288,  313 

diagnosis,  406 
hj-postatic  congestion  of  lungs  in,  248 
immunity,  67 
in  aged,  340 
in  childhood,  330 
abdomen  in,  333 
bed-sores  in,  333 
duration,  331,  335 
febrile  symptoms,  331 
heart  in,  332 
intestines  in,  333 
kidneys  in,  334 
mortality,  336 
nervous  sj-stem  in,  334 
peritonitis  in,  333 
pulse-rate  in,  332 
relapses  in,  336 
respiratory  affections  in,  333 
skin  in,  332 

special  sense  organs  in,  334 
spleen  in,  333 
in  infants,  336 
progno.sis,  339 
pulse  in,  339 
skin  in,  339 
spleen  in,  339 
stools  in,  339 
temperature  in,  339 
vomiting  in,  339 
in  later  lif\j,  340 
diagno.sis,  342 
fever  in,  341 
heart  in,  342 
intestines  in,  342 
kidneys  in,  343 
prognosis,  343 
pul.se  in,  341 
relapses  in,  343 
respiratory  affections  in,  342 
skill  in,  343 
spleen  in,  342 


INDEX. 


643 


Typhoid  fever,  incubation  period,  79 
indictin  in  urine  in,  189 
infection,  effect  of  age  on,  56 
of  cold  on,  64 
of  constitution  on,  62 
of  location  on,  61 
of  mode  of  living  on,  62 
of  occupation  on,  62 
of  pregnancy  on,  61 
of  puerperiuni  on,  61 
of  sex  on,  59 
of  social  state  on,  62 
of  stomach  diseases  on,  66 
external  influences,  70 
factors  favoring,  55 
geographic  influences,  70,  72 
individual  influences,  56 
local  influences,  70 
meteorologic  influence,  73 
nervous  diseases  and,  66 
season  and,  73 
temperature  influence,  75 
weather  and,  75 
inflammation  of  breasts  in,  197 
inflammatory,  313 
inoculation  in,  439 
insanity  and,  268 

intestinal  hemorrhage  in,  97,  217,  465 
pain  in,  214 
perforation  in,  466 
intestines  in,  211 

post-mortem  appearance,  91 
intoxications  and,  328 

differentiation,  414 
irritative,  313 

jaundice  in,  206.     See  also  Jaundice. 
joints  in,  post-mortem  appearance,  89 
kidney  diseases  in,  194 

post-mortem  appearance,  160 
lactophenin  in,  463 
laryngeal  cartilages  in,  242 
symptoms  in,  244 
ulceration  in,  240,  248 
larynx  in,  239 

post-mortem  appearance,  113 
leukocytes  in,  172 
lips  in,  199 
liver  in,  206 

post-mortem  appearance,  101 
localization  theory  of,  23 
loss  of  weight  in,  368 
lung  abscess  in,  254 
lungs    in,    post-mortem    appearance, 

115 
malaria  and,  65,  326 
differentiation,  414 
male  genitalia  in,  194 
malignant,  288 
marasmus  in,  291 
measles  and,  differentiation,  415 
medulla  oblongata  in,  276 

post-mortem  appearance,  121 
meningeal  hemorrhage  in,  273 
meninges  in,  119,  269.     See  also  Men- 
ingitis. 
meningitis  in,  269 


Typhoid  fever,  menstruation  in,  196 
mesent(!ric  glands  in,  100 
meteorism  in,  212,  465 
mild,  temperature  in,  147 
miliaria  crystaliina  in,  128 
milk  and,  45 

mitral  insufficiency  in,  165 
nioiioplegiii  in,  276 
nun'phiiiism  and,  328 
mortality,  383 

age  and,  384 

climate  and,  384 

geographic  differences,  384 

racial  influence  on,  384 

season  and,  384 
motor  manifestations  in,  262 
mouth  in,  199 
mucous,  311 
muscles  in,  post-mortem  appearance, 

87 
muscular  abscess  in,  88 
myelitis  in,  278 
myocarditis  in,  105 

history,  163 

symptoms,  160 
nails  in,  132 
nasal  cavity  in,  113 
nasopharynx  in,  238 
nausea  in,  204 
necrosis  of  intestine  in,  95 

of  larynx  in,  243 
nephritis    in,     111,     191.        See    alsa 

Nephritis. 
nervous  system  in,  259 

post-mortem  appearance,  118 
neuralgia  in,  282 
neuritis  in,  280 

optic,  287 
neuroses  in,  280 
noma  in,  132 
nose  in,  238 
nursing  in,  443 
obliterating  arteritis  in,  169 
of  fetus,  61 
orchitis  in,  194 
osteomj-elitis  and,  89 

differentiation,  414 
ostitis  and,  89 
other  diseases  with,  321 
pancreas  in,  post-mortem  appearance, 

103 
papular  exanthems  in,  128 
paralysis  in,  277.     See  Paralysis. 
paresis  in,  facial,  277 
parotid  gland  in,  202 
parotitis  in,  202 
pathology,  79 
pericarditis  in,  106,  163 
perichondritic  abscess  in,  242 
perichondritis  in,  113,  240 
pei'iostitis  and,  89 
peripheral  nerves  in,  280 

nervous     system     in,    post-mortem 
appearance,  122 
peritonitis  in,  225.     See  Peritonitis. 
perforative  in,  96,  98 


644 


INDEX. 


Typhoid  fever,  perityphlitis  and,  differen- 
tiation, 408" 
perityphlitis  in,  23(j 
Fever's  patches  in,  93,  98 
pharynx  in,  200 
phenacetin  in,  4G2 
plilehitis  in.  107,  1()0 
plilcn-Miasia  alba  doleiis  in,  169 
piiU'guions  in,  l^O 

pia-arachnoid  in,  post-mortfni  appear- 
ance, 119 
pleurisy,  ditlerential  diagnosis,  418 
pleurisy  in,  117,  257 
pneumonia,  ditlerential  diagnosis,  418. 

See  also  Pneimwnia. 
pneumothorax  in,  258 
pti.^t-niortcm  ctmdititms,  80 
pregnancy  and,  relation  of,  197 
preventive  inoculation  in,  09 
prognosis,  382 

albuminuria  in,  394 
circulatory  organs  and,  390 
constitution  and,  387 
health  and,  387 
intestinal  hemorrhage  in,  393 
intestines  and,  392 
kidnev  in,  394 
lungs'in,  391,  393 
nephritis  in,  394 
occupation  and,  386 
peritonitis  and,  392 
pleurisy  in,  394 
pneumonia  in,  393 
sex  and,  385 
social  position  and,  386 
temperature  and,  390 
prophylactics  of  laity,  47 
prophylaxis,  individual,  434 

measures  for,  431 
protracted,  290 
psychoses  in,  265 
pulmonary  gangrene  in,  255 
infarction  in,  255 
tuberculosis  and,  06,  118 
pulse  in,  81,  152.     See  also  Pulse. 
pulse-temperature  of,  136 
pyuria  in,  191 

recrudescence  in,  course,  86,  344,  356, 
365 
relapse  with,  363 
terminations,  356 
recrudescent,  291 
red  corpuscles  in,  170 
reflexes  in,  279,  283 
relapse  in,  344 
ahortive,  359 
afebrile,  359 
age  and,  360 
cause,  365 
character  of,  357 
omu'se,  356 
diagnosis  and,  410 
duration,  357,  358 
fi-equency  of,  359 
intestinal  symptoms,  355 
mortality,  357 


Typhoid  fever,  relapse  in,  nervous  system 
in,  356 
prognosis,  388 
pulse  in,  352 
recrudescence  with,  368 
repeated,   363 

respiratory  atlections  in,  356 
roseohe  in,  353 
sex  and,  300 
spleen  in,  346,  354 
temperature  in,  346,  349 
terminations,  356 
time  of,  345 
relapses  in,  86,  471 
relapsing  fever,  differential  diagnosis, 

417 
repeated  attacks,  67 
respiratory  organs  in,  238 

post-mortem  appearance,  113 
retinal  hemorrhages  in,  287 
rheumatic  polyarthritis  M'ith,  327 
roseola  in,  absence  of,  125 
of,  blood  from,  127 
life  of,  125 

typhus  eruption  and,  127 
roseolas  cultures,  aid  in  diagnosis,  423 
roseola?  of,  83,  124 
rotheln  with,  322 

salivary  glands,  post-mortem   appear- 
ance, 90 
scarlet  fever  and,  differentiation,  415 
scarlet  fever  with,  321 
.sciatica  in,  282 
sclerosis  in,  279 

secondary  syphilis,    diflerential    diag- 
nosis,'418 
septicemia  and,  differentiation,  413 
septicemia    in,  cerebrospinal    menin- 
gitis with,   273 
septicemic,  323 
severe,  290 

of  atvpical  course  and   symptoma- 
tology, 811 
sewage  conditions  in,  431 
short  malignant,  288 
sick-bed  in,  444 
sick-room  disinfection  in,  437 
skin  in,  83,  124,  469 
sleepiness  in,  260 
small-pox  and,  65,  322 

ditferentiation,  415 
soil  in  etiology  of,  51 
spinal  cord  in,  278 

post-mortem  appearance,  121 
spleen  in,  176 

post-mortem  appearance,  107 
puncture  of,  422 
sporadic  cases,  76 
.stomach  in,  204 

post-mortem  appearance,  91 
stools,  di.sinfection  of,  435 
stools  in,  214.     See  also  Stools. 
subsultus  tendinumin,  263 
sudamina  in,  301 
symptomatology,  79 
variations  in,  287 


INDEX. 


645 


Typhoid  fever,  symptoms,  83,  122 
in  incubation  period,  80 
temperature,  ascent  of   137,  142 
descent  of,  138 
high,  144 

during  convalescence,  86 
multiple  elevations,  140 
peculiarities  of,  144 
variations  in,  137 
temperature-curve,  ascent  of,  142 
in  mild  cases,  147 
in  stage  of  defervescence,  149 
tendon-jerking  in,  263 
tetanus-like  condition  in,  264 
third  febrile  period,  137 
thrombosis  in,  167 
thyroid  gland  in,  183 
thyroiditis  in,  184 
tongue  in, 199 

post-mortem  appearance,  90 
tonsils  in,  201 
toxic  action  on  nervous  system  in,  265 

symptoms,  303 
trachea  in,  245 

post-mortem  appearance,  114 
treatment,  antipyretic  methods  in,  453, 
460 
baths,  456 
hydrotherapy,  454 
intestinal  antisepsis  in,  441 
serum,  440 
specific,  440 
tremor  in,  263 
trichinosis  and,  ditfereiitial  diagnosis, 

418 
trismus  in,  264 

tuberculosis  and,  differentiation,  410 
typhus  and,  differentiation,  415,  600 
relation  between,  564 
roseoliB  in,  599 
ulcers  of  intestine  in,  96,  98 
urea  in,  185 
uric  acid  in,  186 
ui-inary  apparatus  in,  184 

organs  in,  post-mortem  appearance, 
110 
urine  in,  84 
urobilinuria  in,  189 
urticaria  in,  128 

uterine  mucous  membrane  in,  196 
vascular  system  in,  post-mortem  ap- 
pearance, 104 
veins  in,  169 
vomiting  in,  204 
water-supply  in,  432 
Widal  reaction  in,  29 
without  intestinal  lesions,  39,  99 
without  tvphoid  stools,  216 
Typhoid  spine,  280 
stools,  214 

toxins,  symptoms  due  to,  303 
Typhoidal  state,  260 
Typhoidette,  293 
Typhomalarial  fever,  326 
Typhus  abortivus,  293 
ataxicus,  554 


Typhus  ataxo-adynamicus,  554 
baths  ill,  620 
carcerum,  588 
cutarrhalis,  555 
dysentericuH,  554 
exanthem,  527 
Typhus  fever,  475 

aliortive  cases,  558 

alcoholism  and,  relation  between,  564 

ambulatory  cases,  561 

anthrax  and,  differential  diagnosis,  603 

antipyretic  methods  of  treatment,  610 

remedies,  621 
blood  changes  in,  525 
cadavers  of,  609 

care  of  articles  used  by  patients,  608 
cerebrospinal  meningitis  and,  differen- 
tial diagnosis,  598 
changes  in  blood-vessels  in,  525 
in  circulatory  organs,  523 
in  digestive  tract,  547 
in  genito-urinary  organs,  548 
in  heart,  525 
in  nervous  system,  534 
in  pulse,  523 

in  respiratory  organs,  542 
in  skin,  627 
chronic    affections    and,    relation   be- 
tween, 564 
condition  of  organs  during  convales- 
cence, 570  " 
constitution,  effect  of,  565 
convalescence,  627 
convalescents,  discharge  of,  610 
course  of  variations  in  manifestations, 

551,  554 
cryptogenic    septicopyemia   and,  dif- 
ferential diagnosis,  597 
diagnosis,  594 

_  in  stage  of  eruption,  598 
diagnostic    significance    of   eruption, 

598 
diet,  616 

different  forms  of,  temperature  varia- 
tions in,  518 
digestive  organs,  627 
disinfection'of  bed-linen,  608 
of  furnishings,  609 
of  outer  clothing,  608 
of  sick-rooms,  609 
of  wards,  609 
distribution,  480 
duration,  569 
endemics,  497 
epidemics,  497 
erysipelas  in,  533 

exanthemata  and,  differential  diagno- 
sis, 603 
relation  between,  562 
fatal  cases,  575 
general  conditions,  493 
glanders    and,    differential   diagnosis, 

603 
history,  475 
hydrotherapy,  619 
hygienic  conditions  in  prophylaxis.  604 


G46 


ISDEX. 


Typhus  fever,  imnumity,  489 
ill  cliiklhood,  507 
incubation  stage,  500 
isolation  in  prophylaxis,  GOG 
lymph-gland  changes,  526 
malarial  fever  and,  differential  diagno- 
sis, 5!)7 
manifestations,  variations  in,  551 
meteorologic   conditions   predisposing 

to,  497 
mild  cases,  555 
morbid  anatomy,  507 
mortality,  575,  585 

age  in,  585 

external  conditions  in,  585 

geographic  distribution  in,  585 

mode  of  life,  587 

occupation  in,  587 

personal  conditions  in,  585 

time  of  year  in,  585 

weather  in,  585 
nervous  symptoms,  624 

system,  512 
noma  in,  583 
nursing,  613 

occupation  predisposing  to,  496 
old  age,  effect  of,  566 
open-air  treatment,  615 
period  of  convalescence,  569 

of  defervescence,  temperature  in,  516 

of  greatest  danger  of  infection,  486 
pneumonia  and,  differential  diagnosis, 

603 
prognosis,  575,  585 

age  in,  585 

digestive  organs  in,  591 

external  conditions  in,  585 

eye  in,  591 

general  s\Tnptoms,  589 

hemorrhagic  phenomena,  592 

individual  organs  in,  589 

meteorism  in,  592 

mode  of  life  in,  587 
of  onset  in,  589 

nervous  system  in,  590 

occupation  in,  587 

personal  conditions  in,  585 

respiratory  organs  in,  591 

severity  of  symptoms  in,  589 

skin  in,  592 

time  of  year  in,  585 

weather  in,  585 
prophylaxis,  604 
recurrences  in,  551 
relapses  in,  551 

relapsing  fever  and,  differential  diagno- 
sis, 596 
respiratory  organs  in,  626 
roseola  in,  504 
scarlatina  and,  differential  diagnosis, 

603 
season,  497 
sex  in,  490 

effect  of,  566 
skin  changes  in,  527 
social  conditions  in,  496 


Typhus  fever,  spleen  changes  in,  526 
susceptibility,  489 
sweating,  521 
synipt(jms,  513 
temperature  in,  513 

in  beginning  stages,  514 
in  later  stages,  514 
transmission  of,  by  dead  bodies,  485 
transportation  of  patients   606 
treatment,  baths,  620 
hydrotherapy,  619 
of  organic  changes,  622 
of  special  conditions,  622 
open-air,  615 
specific,  612 
tvphoid  and,  differentiation,  415 
'  rosc.lif  in,  599 

variola  and.  differential  diagnosis,  596 
ventilation  in  treatment,  615 
washing  of  hospital  clothing,  607 
levissimus,  293 
nervosus,  554 
siderans,  580 

Urea  in  typhoid,  185 
Uric  acid  in  typhoid,  186 
Urinary  apparatus  in  typhoid,  184 

organs  in  convalescence  from   tj^hoid, 
378 
in  typhoid,  post-mortem  appearance, 
110 
Urine,  bacillus  typhosus  in,  32,  34 
vitality,  37 
disinfection  of,  in  tvphoid,  436 
in  typhoid,  112,  184 
Urobilinuria  in  typhoid,  189 
Urticaria  in  typhoid,  128 
Uterine   mucous   membrane    in    typhoid, 
196 

Yariola,    typhoid     and,    differentiation, 

415 
typhus  and,  differential  diagnosis,  595 
with  typhoid,  322 
Vascular  system  in  typhoid,  post-mortem 

appearance,  104 
Yenous  thrombosis  in  convalescence  from 

typhoid,  374 
Yersatile  nervous  fever,  312 
Yomiting  in  typhoid,  204 

Water,  bacillus  typhosus  in,  vitality,  36 
disinfection  of,  in  typhoid,  437 
role  of,  in  typhoid,  40 
Well-water,  tvphoid  fever  from,  41,  43 
Widal  reaction,  29,  425 

earliest  appearance  of,  427 

in  typhoid,  423 

macroscopic  method  in,  426 

microscopic  method  in,  426 

occurrence   of,  time   elapsing   before,, 
429 

prognostic  significance  of,  430 

relation  of  serum  and  culture  in,  428 

specificity  of,  427 
Widal's  method  of  agglutination,  425 


SAUNDER-S'    BOOKS 

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SA  rxn/-:A's'  books  on 


American 
Text-Book  of  Surgery 

American  Text=Book  of  Surgery.  Edited  by  William  W.  Keen, 
M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Professor  of  the  Principles  of  Sur- 
ger}-  and  of  Clinical  Surger\',  Jefferson  Medical  College,  Philadel- 
phia;  and  J.  William  White,  M.D.,  Ph.D.,  John  Rhea  Barton 
Professor  of  Surgery,  University  of  Pennsj^lvania.  Handsome  octavo, 
1230  pages,  with  496  wood-cuts  in  the  text  and  37  colored  and  half- 
tone plates.         Cloth,  $7.00  net ;  Sheep  or  Half  Morocco,  ^8.00  net. 

THIRD  EDITION.  THOROUGHLY  REVISED  AND  ENLARGED 

Of  the  two  former  editions  of  this  book  there  have  been  sold  over  36,000 
copies.  This  and  its  adoption  as  a  text-book  in  eighty-five  medical  colleges 
have  furnished  a  stimulus  to  the  authors  to  keep  the  work  abreast  of  the  times 
by  another  careful  revision.  This  has  been  accomplished  by  a  vigorous  scrutiny 
of  all  the  old  matter,  by  the  enlargement  of  several  sections,  by  the  addition  of 
new  illustrations,  and  by  the  introduction  of  the  many  new  topics  that  have  come 
to  the  front  in  the  surgery  of  to-day.  Among  the  new  topics  introduced  are 
a  full  consideration  of  serum-therapy  ;  leucocytosis  ;  post-operative  insanity ; 
Kronlein's  method  of  locating  the  cerebral  fissures  ;  Hoffa's  and  Lorenz's  oper- 
ations of  congenital  dislocations  of  the  hip  ;  AUis'  researches  on  dislocations  of 
the  hip-joint ;  lumbar  puncture  ;  the  forcible  reposition  of  the  spine  in  Pott's  dis- 
ease ;  the  use  of  Kelly's  rectal  specula  ;  the  use  of  eucain  for  local  anesthesia  ; 
Krause's  method  of  skin-grafting,  etc. 


PERSONAL  AND  PRESS  OPINIONS 

Edmund  Owen,  F.R..C.S., 

Member  of  the  Boa?-d  of  Examiners  of  the  Royal  College  of  Sjirgeofis,  England. 
"  Personally,  I  should  not  mind  it  being  called  The  Text-Book  (instead  of  A  Text-Book),  for  I 
know  of  no  single  volume  which  contains  so  readable  and  complete  an  account  of  the  science  and  art 
of  surgery  as  this  does." 

The  La.ivcet,  Londoiv 

"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must  admit  it 
is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very  carefully  to  their 
laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." 

Boston  Medica.1  a^nd  Surgical  Journal 

"  This  book  marks  an  epoch  in  American  book-making.  All  in  all,  the  book  is  distinctly  the 
most  satisfactory  work  on  modern  surgery  with  which  we  are  familiar.  It  is  thorough,  complete,  and 
condensed." 


SURGERY  AND  ANATOAfV 


Irvterrvatiorval 
Text-Book  of  Surgery 

SECOND  EDITION.  THOROUGHLY  REVISED  AND  ENLARGED 

The  International  Text=Book  of  Surgery.  In  two  volumes.  By- 
American  and  British  authors.  Edited  by  J.  Collins  Warren,  M.D., 
LL.D.,  F.R.C.S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical 
School;  and  A.  Pearce  Gould,  M.S.,  F.R.C.S.,  of  London,  England. — 
Vol.  I.  General  and  Operative  Surgery.  Royal  octavo,  975  pages, 
461  illustrations,  9  full-page  colored  plates. — Vol.  II.  Special  or 
Regional  Surgery.  Royal  octavo,  1122  pages,  499  illustrations,  and 
8  full-page  colored  plates. 

Per  volume  :   Cloth,  ;^5.oo  net;   Half  Morocco,  ^6.00  net, 

ADOPTED  BY  THE  U.  S.  AR_MY 

In  this  new  edition  the  entire  book  has  been  carefully  revised,  and  special  effort 
has  been  made  to  bring  the  work  down  to  the  present  day.  The  chapters  on 
Military  and  Naval  Surgery  have  been  very  carefully  revised  and  extensi\-ely 
rewritten  in  the  light  of  the  knowledge  gained  during  the  recent  wars.  The 
articles  on  the  effect  upon  the  human  body  of  the  various  kinds  of  bullets,  and 
the  results  of  surgery  in  the  field  are  based  on  the  latest  reports  of  the  sur- 
geons in  the  field.  The  chapter  on  Diseases  of  the  Lymphatic  System  has  been 
completely  rewritten  and  brought  up  to  date  ;  and  of  special  interest  is  the 
chapter  on  the  Spleen.  The  already  numerous  and  beautiful  illustrations  have 
been  greatly  increased,  constituting  a  valuable  feature,  especially  so  the  seven- 
teen colored  lithographic  plates. 


OPINIONS  OF  THE  MEDICAL  PRESS 

AnnsLls  of  Surgery 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  j-ears.  The  clinician  and 
the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a  satisfaction  to  the  editors 
as  it  is  a  gratification  to  the  conscientious  reader." 

Boston  MedicaLl  SLnd  Surgicek.!  JournaLl 

"  The  articles  as  a  rule  present  the  essentials  of  the  subject  treated  in  a  clear,  concise  manner. 
They  are  systematically  written.  The  illustrations  are  abundant,  well  chosen,  and  enhance  greatly 
the  value  of  the  work.     The  book  is  a  thoroughly  modern  one." 

The  MedicaLl  Kecord,  New  York 

"The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different  authors  is 
equally  so.  .  .  .  The  work  is  up  to  date  in  a  very  remarkable  degree,  many  of  the  latest  operations  m 
the  different  regional  parts  of  the  body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work 
from  which  the  reader  may  not  learn  something  new." 


SAUNDERS'  BOOKS  ON 


Senn's 
Practical  Surgery 

Practical  Surgery.  A  Work  for  the  General  Practitioner.  By 
Nicholas  Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  Suri;ery  in  Rush 
Medical  College,  Chicago  ;  Professor  of  Surgery  in  the  Chicago  Poly- 
clinic ;  Attending  Surgeon  to  the  Presbyterian  Hospital,  etc.  Hand- 
some octavo  volume  of  1133  pages,  with  650  illustrations,  many  of 
them  in  colors.  Cloth,  $6.00  net ;  Sheep  or  Half  Morocco,  $7.00  net. 
Sold  by  Subscription. 

DR..  SENN'S  GREAT  WORK 
Based  on  His  Operative  Experience  for  25  Years 

This  work  represents  the  practical  operative  experience  of  the  author  for  the 
last  twenty-five  years.  The  book  deals  with  practical  subjects,  and  its  contents 
are  devoted  to  those  sections  of  surgery  that  are  of  special  interest  to  the  general 
practitioner.  Special  attention  is  paid  to  emergency  surgery.  Shock,  hemor- 
rhage, and  wound  treatment  are  fully  considered.  All  emergency  operations 
that  come  under  the  care  of  the  general  practitioner  are  described  in  detail  and 
fully  illustrated. 

The  section  on  Military  Surgery  is  based  on  the  author's  experience  as 
chief  of  the  operating  staff  in  the  field  during  the  Spanish-American  War,  and 
on  his  observations  during  the  Greco-Turkish  War.  Intestinal  Surgery  is  given 
a  prominent  place,  and  the  consideration  of  this  subject  is  the  result  of  the 
clinical  experience  of  the  author  as  surgeon  and  teacher  of  surgery  for  a  quarter 
of  a  century.     The  text  is  profusely  illustrated. 


OPINIONS  OF  THE  MEDICAL  PRESS 

Anna.ls  of  Surgery 

"  It  is  of  value  not  only  as  presenting  comprehensively  the  most  advanced  teachings  of  modern 
surgery  in  the  subjects  which  it  takes  up.  but  also  as  a  record  of  the  matured  opinions  and  practice  of 
an  accomplished  and  experienced  surgeon." 

Qua.r<erly  Medical  Journal,  England 

"  We  cannot  speak  too  highly  of  this  valuable  contribution  to  the  literature  of  practical  surgery. 
.  .  .  The  present  work  more  than  sustains  the  high  reputation  of  its  author." 

Buffalo  Medical  Journal 

"  As  an  intelligent  exposition  of  the  science  of  surgery  as  practiced  to-day  it  is  deserving  of 
commendation,  and  it  vi-ill  be  particularly  welcomed  by  the  general  practitioner." 


SURGER  Y  AND  ANA  TOMY 


Sc\jdder*s 
Treatment  of  Fractures 

The  Treatment  of  Fractures.  By  Charles  L.  Scudder,  M.D., 
Assistant  in  Clinical  and  Operative  Surgery,  Harvard  Medical  School ; 
Surgeon  to  the  Out-Patient  Department  of  the  Massachusetts  General 
Hospital,  Boston.  Handsome  octavo  volume  of  485  pages,  with 
645  original  illustrations. 

Polished  Buckram,  ^4.50  net;  Half  Morocco,  $^.^0  net. 

THE  THIRD  LARGE  EDITION  IN  TWO  YEARS 

In  this  edition  several  new  fractures  have  been  described,  and  an  excellent 
chapter  on  Gunshot  Fractures  of  the  long  bones  has  been  added.  The  reports 
of  surgeons  in  the  field  during  the  recent  wars  have  been  carefully  digested,  and 
the  important  facts  regarding  fractures  produced  by  the  small  caliber  bullet  have 
been  here  concisely  presented.  In  many  instances  photographs  have  been  substi- 
tuted for  drawings,  and  the  uses  of  plaster-of-Paris  as  a  splint-material  have  been 
more  fully  illustrated .  In  the  treatment  the  reader  is  not  only  told,  but  is  shown, 
how  to  apply  apparatus,  for  as  far  as  possible  all  the  details  are  illustrated.  This 
elaborate  and  complete  series  of  illustrations  constitutes  a  feature  of  the  book. 
There  are  645  of  them,  all  from  new  and  original  drawings  and  reproduced  in 
the  highest  style  of  art. 


PERSONAL  AND  PRESS  OPINIONS 

William  T.  Bull.  M.D.. 

Professor  of  Surge7y,  College  of  Physicians  and  Surgeons,  New  York  City, 
"  The  work  is  a  good  one,  and  I  shall  certainly  recommend  it  to  students." 

Joseph  D.  BryaLiit,  M.D., 

Professor  of  the  Principles  and  Practice  of  Surgery,  University  atid  Bellevue  Hospital 
Medical  College,  New  York  City. 
"  As  a  practical  demonstration  of  the  topic  it  is  excellent,  and  as  an  example  of  bookmaking  it 
is  highly  commendable." 

American  JournaLl  of  the  MedicaLl  Sciences 

"  The  work  produces  a  favorable  impression  by  the  general  manner  in  which  the  subject  is 
treated.  Its  descriptions  are  concise  and  clear,  and  the  treatment  sound.  The  physical  examination  of 
the  injured  part  is  well  described,  and  .  .  .  the  method  of  making  these  examinations  is  illus- 
trated by  a  liberal  use  of  cuts." 


SAUA'DEHS'  BOOKS  ON 


D».Costa^*s 

Moderrv    Svirgery 

Modern  Surgery — General  and  Operative.  By  John  Chalmers 
DaCosta,  M.D.,  Professor  of  the  Principles  of  Surgery  and  of  Clinic 
cal  Surgery  in  the  Jefferson  Medical  College,  Philadelphia  ;  Surgeon 
to  Philadelphia  Hospital  and  to  St.  Joseph's  Hospital,  Philadelphia. 
Handsome  octavo  volume  of  1 1 17  pages,  copiously  illustrated. 

Cloth,  $5.00  net ;  Sheep  or  Half  Morocco,  $6.00  net. 

THIRD  REVISED  EDITION 

Enlarged  by  over  200  Pages,  with  over  100  New  Illustrations 

The  remarkable  success  attending  DaCosta' s  Manual  of  Surgery,  and  the 
general  favor  with  which  it  has  been  received,  have  led  the  author  in  this  revi- 
sion to  produce  a  complete  treatise  on  modern  surgery  along  the  same  lines  that 
made  the  former  editions  so  successful.  The  book  has  been  entirely  rewritten 
and  very  much  enlarged  in  this  edition.  It  has  been  increased  in  size  by  new 
matter  to  the  extent  of  over  200  pages,  and  contains  more  than  100  handsome 
new  illustrations,  making  a  total  of  439  beautiful  cuts  in  the  text.  The  old 
editions  of  this  e.xcellent  work  have  long  been  favorites,  not  only  with  students 
and  teachers  but  also  with  practising  physicians  and  surgeons,  and  it  is  believed 
that  the  present  work,  presenting,  as  it  does,  the  latest  advances  in  the  science 
and  art  of  surgery,  will  find  an  even  wider  field  of  usefulness. 


OPINIONS  OF  THE  MEDICAL  PRESS 

The  Lancet,  London 

"  We  may  congratulate  Dr.  DaCosta  in  the  success  of  his  attempt.  .  .  .  We  can  recommend 
the  work  as  a  text-book  well  suited  to  students." 

The  Medical  Record,  New  York 

"  The  work  throughout  is  notable  for  its  conciseness.  Redundance  of  language  and  padding 
have  been  scrupulously  avoided,  while  at  the  same  time  it  contains  a  sufficient  amount  of  information 
to  fulfil  the  object  aimed  at  by  its  author— namely,  a  text-book  for  the  use  of  the  student  and  the 
busy  practitioner." 

American  Journal  of  the  Medical  Sciences 

"The  author  has  presented  concisely  and  accurately  the  principles  of  modern  surgery.  The 
book  is  a  valuable  one,  which  can  be  recommended  to  students,  and  is  of  great  value  to  the  general 
practitioner." 


SURG  EN  V  AND  ANA  TO  MY 


McClellan's 
Art    Ana».toiTvy 

Anatomy  in  its  Relation  to  Art.  An  exposition  of  the  Bones 
and  Muscles  of  the  Human  Body,  with  Reference  to  their  Influence 
upon  its  Actions  and  external  Form.  By  George  McClellan,  M.D,, 
Professor  of  Anatomy,  Pennsylvania  Academy  of  the  Fine  Arts. 
Handsome  quarto  volume,  9  by  ii^  inches,  lllu.strated  with  338 
original  di'awings  and  photographs,  with  260  pages  of  text. 

Dark  Blue  Vellum,  ^10.00  net;   Half  Russia,  ^12.00  net 

J\ist  Issued 

This  is  an  exhaustive  work  on  the  structure  of  the  human  body  as  it  affects 
the  external  form,  and  ahhough  especially  prepared  for  students  and  lovers  of 
art,  it  will  prove  very  valuable  to  all  interested  in  the  subject  of  anatomy.  It 
will  be  of  especial  value  to  the  physician,  because  nowhere  else  can  he  find  so 
complete  a  consideration  of  surface  anatomy.  Those  interested  in  athletics  and 
physical  training  will  find  reliable  information  in  this  book. 

Howard  Pyle, 

In  the  Philadelphia  Medical  Journal. 
"  The  book  is  one  of  the  best  and  the  most  thorough  Text-books  of  artistic  anatomy  which  it  has 
been  the  writer's  fortune  to  fall  upon  and,  as  a  text-book,  it  ought  to  make  its  way  into  the  field  for 
which  it  is  intended." 

McClellan's 
ILegiorvscl  Arva^torrvy 

Regional  Anatomy  in  its  Relations  to  Medicine    and  Surgery. 

By  George  McClellan,  M.D.,  Professor  of  Anatomy,  Pennsylvania 
Academy  of  the  Fine  Arts.  Two  handsome  quartos,  884  pages  of  text ; 
97  full-page  chromolithographic  plates,  reproducing  the  author'  s  orig- 
inal dissections.  Cloth,  $12.00  net;    Half  Russia,  315.00  net. 

Fourth  R^evised  Edition 

This  well-known  work  stands  without  a  parallel  in  anatomic  literature,  and  its 
remarkably  large  sale  attests  its  value  to  the  practitioner.  By  a  marvelous  series 
of  colored  lithographs  the  exact  appearances  of  the  dissected  parts  of  the  body 
are  reproduced,  enabling  the  reader  to  examine  the  anatomic  relations  with  as 
much  accuracy  and  satisfaction  as  if  he  had  the  actual  subject  before  him. 

British  Medical  Journal 

"The  illustrations  are  perfectly  correct  anatomical  studies,  and  do  not  reproduce  the  inaccura- 
cies which  experience  has  taught  us  to  look  for  in  works  of  a  similar  kind.  Some  of  the  plates, 
especially  those  of  the  anatomy  of  the  chest,  are  of  great  excellence." 


8  SAUNDERS'  BOOKS  ON 

GET  JL       _^  •  THE  NEW 

THE  BEST       >lLrX\©riCQk.rV        standard 

Illustracted    Dictionocry 

.    SECOND  EDITION.  R.EVISED 

The    American    Illustrated    Medical    Dictionary.     A    New   and 

Complete  Dictionary  of  the  terms  used  in  Medicine,  Surgery,  Den- 
tistr)',  Pliarmac}',  Chcmistr}',  and  kindred  branches  ;  together  with  new 
and  elaborate  tables  of  Arteries,  Muscles,  Nerves,  Veins,  etc.;  of 
Bacilli,  Bacteria,  Micrococci,  etc.;  Eponymic  Tables  of  Diseases, 
Operations,  Signs  and  Symptoms,  Stains,  Tests,  -Methods  of  Treat- 
ment, etc.  By  W.  A.  N.  Dorland,  M.D.  Large  octavo,  770  pages. 
Flexible  leather,  $4.50  net;  with  thumb  index,  ^5.00  net. 
LARGE  FIRST  EDITION  EXHAUSTED  IN  EIGHT  MONTHS 

In  this  edition  the  l^ook  has  been  subjected  to  a  thorough  revision.  The 
author  has  also  added  upward  of  one  hundred  important  new  terms  that  have 
appeared  in  medical  hterature  during  the  past  few  months. 

HowsLrd  A.  Kelly.  M.D., 

J  Professor  of  Gynecology,  Johns  Hopkins  University,  Baltimore. 

"  Dr.  Dorland's  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient  size. 
Kg  errors  have  been  found  in  ni\'  use  of  it." 

R.oswell  PjLrk.  M.D., 

Professor  of  Principles  and  Practice  of  Surgery  and  of  Clinical  Surgery, 
University  of  Buffalo. 
'■'  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  within  relatively 
small  space.     1  find  nothing  to  criticise,  very  much  to  commend,  and  was  interested  in  finding  some 
of  the  new  words  which  are  not  in  other  recent  dictionaries." 

American  Year-Book 

Saunders'    American    Year  =  Book    of    Medicine    and    Surgery. 

A  yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  foreign  authors  and  inves- 
tigators. Arranged,  with  critical  editorial  comments,  by  eminent 
American  specialists,  under  the  editorial  charge  of  George  M.  Gould, 
A.M.,  M.D.  In  two  volumes  :  Vol.  I — General  Medicine,  octavo,  715 
pages,  illustrated  ;  Vol.  II — General  Surgery,  octavo,  684  pages,  illus- 
trated. Per  vol.:  Cloth,  ^3.00  net ;  Half  Morocco,  $1.7^  net.  Sold 
by  Subscription. 

In  these  volumes  the  reader  obtains  not  only  a  yearly  digest,  but  also  the 
invaluable  annotations  and  criticisms  of  the  editors.  As  usual,  this  issue  of  the 
Year-Book  is  amply  illustrated. 

The  Lancet,  London 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted  to 
experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  commentaries  and 
expositions    .    .    .    proceeding  from  writers  fully  qualified  to  perform  these  tasks." 


SURGER  Y  AND  ANA  7VMV 


Helferich  and  Bloodgood's 
Fractures  and   Dislocations 

Atlas  and   Epitome  of  Traumatic    Fractures  and    Dislocations. 

By  Professor  Dr.  H.  Helfekicm,  Professor  of  Surgery  at  the  Royal 
University,  Greifswald,  Prussia.  Pvditecl,  with  additions,  by  Joseph  C. 
Bloodgood,  M.D.,  Associate  in  Surgery,  Johns  Hopkins  University, 
Baltimore.  Fi^oj/i  the  Fifth  Revised  and  Enlarged  German  Edition. 
With  216  colored  illustrations  on  64  hthographic  plates,  190  text-cuts, 
and  353  pages  of  text.      Cloth,  ;^3.oo  net.     In  Saunders^  Atlas  Series. 

A  New  Volume — J\ist  Issued 

A  book  accurately  portraying  the  anatomic  relations  of  the  fractured  parts, 
together  with  the  diagnosis  and  treatment  of  the  condition,  has  become  an  abso- 
lute necessity.  This  work  is  intended  to  meet  all  reciuirements.  As  complete  a 
view  as  possible  of  each  case  has  been  presented,  thus  equipping  the  physician 
for  the  manifold  appearances  that  he  will  meet  with  in  practice.  The  illustra- 
tions are  unrivaled  for  accuracy  and  clearness  of  portrayal  of  the  conditions 
represented,  showing  the  visible  external  deformity,  the  X-ray  shadow,  the  ana- 
tomic preparation,  and  the  method  of  treatment. 

Zuckerkandl   and   DaCosta's 
Opera^utive    S\jrgery 

ADOPTED  BY  THE  U.  S.  ARMY 

Atlas  and  Epitome  of  Operative  Surgery.  By  Dr.  O.  Zucker- 
kandl, of  Vienna.  Edited,  with  additions,  by  J.  Chalmers  DaCosta, 
M.D.,  Professor  of  the  Principles  of  Surgery  and  Clinical  Surgery,  Jef- 
ferson Medical  College,  Philadelphia.  40  colored  plates,  278  text-cuts, 
and  410  pages  of  text.     Cloth,  ^3.50  net.     In  Saunders'  Atlas  Series. 

SECOND  EDITION.  THOROUGHLY  REVISED  AND  GR.EATLY  ENLARGED 

In  this  new  edition  the  work  has  been  brought  precisely  down  to  date.  A 
number  of  chapters  have  been  practically  rewritten,  and  of  the  newer  operations, 
all  those  of  special  value  have  been  described.  Sixteen  valuable  lithographic 
plates  in  colors  and  sixty-one  text  figures  have  been  added,  thus  greatly  enhancing 
the  value  of  the  work. 

New  York  Medical  Journal 

"  We  know  of  no  other  work  upon  the  subject  in  which  the  illustrations  are  as  numerous  or  as 
generally  satisfactory." 


lo  S.-^iWnE/^S'   BOOKS  ON 

Macdoaatld's 
DioLgivosis  a.nd   TredLtment 

A  Clinical  Text=Book  of  Surgical  Diagnosis  and  Treatment.    By 

J.  W.  ]\Iacdonald,  IM.D.  I'xlin.,  F.R.C.S.  Edin.;  Professor  Kmeritus 
of  the  Practice  of  Surgery  and  of  Clinical  Surgcr}Mn  Ilamlinc  Uni- 
versity, Minneapolis,  Minn.  Octavo,  798  pages,  handsomely  illus- 
trated. Cloth,  $5.00  net ;  Sheep  or  Half  Morocco,  $6.00  net 

This  work  aims  to  furnish  a  guide  to  surgical  diagnosis.  It  sets  forth  in  a 
systematic  way  the  necessity  of  examinations  and  the  proper  methods  of 
making  them.  The  various  portions  of  the  body  are  then  taken  up  in  order  and 
the  diseases  and  injuries  thereof  succinctly  considered  and  the  treatment  briefly 
indicated.  Practically  all  the  modern  and  approved  operations  arc  described. 
The  work  concludes  with  a  chapter  on  the  use  of  the  Rontgen  rays  in  surgery. 

British  Medica.!  JournaLl 

"  Care  has  been  taken  to  lay  down  rules  for  a  systematic  and  comprehensive  examination  of 
each  case  as  it  presents  itself,  and  the  most  advanced  and  approved  methods  of  clinical  investigation 
in  surgical  practice  are  fully  described." 

Warren's 
PaLtKology  aLivd  TKerapeutics 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  War- 
ren, M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Professor  of  Surgery,  Harvard 
Medical  School.  Octavo,  873  pages;  136  relief  and  lithographic 
illustrations,  33  in  colors.  With  an  Appendix  on  Scientific  Aids  to 
Surgical  Diagnosis  and  a  series  of  articles  on  Regional  Bacteriology. 
Cloth,  ^5.00  net;    Sheep  or  Half  Morocco,  ^6.00  net 

SECOND   EDITION.  WITH  AN  APPENDIX 

The  volume  is  for  the  bedside,  the  amphitheatre,  and  the  ward.  It  deals 
with  diseases  not  as  we  see  them  through  the  microscope  alone,  but  as  the  prac- 
titioner sees  their  effect  in  his  patients  ;  not  only  as  they  appear  in  and  affect 
culture-media,  but  also  as  they  influence  the  human  body  ;  and,  following  up 
the  demonstrations  of  the  nature  of  diseases,  the  author  points  out  their  logical 
treatment. 

Roswell  PeLrk.  M.D., 

I71  the  Harvard  Gradiiale  Magazine. 

"  I  think  it  is  the  most  creditable  book  on  surgical  pathology,  and  the  most  beautiful  medical 
illustration  of  the  bookmakers'  art  that  has  ever  been  issued  from  the  American  press." 


SURGER  V  AND  ANA  TOMY  1 1 


Golebiewski  and  Bailey's 
Accidervt  Disea^ses 

Atlas  and  Epitome  of  Diseases  Caused    by  Accidents.     By  Dr. 

Ed.  Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce 
Bailey,  M.D.,  Attending  Physician  to  the  Almshouse  and  Incurable 
Hospitals,  New  York.  With  71  colored  figures  on  40  plates,  143  text- 
cuts,  and  549  pages  of  text.  Cloth,  1^4.00  net.  In  Saunders'  Hand- 
Atlas  Series. 

This  work  contains  a  full  and  scientific  treatment  of  the  subject  of  accident 
injury  ;  the  functional  disability  caused  thereby  ;  the  medicolegal  questions  in- 
volved, and  the  amount  of  indemnity  justified  in  given  cases.  The  work  is  in- 
dispensable to  every  physician  who  sees  cases  of  injury  due  to  accidents,  to  ad- 
vanced students,  to  surgeons,  and,  on  account  of  its  ilkistrations  and  statistical 
data,  it  is  none  the  less  useful  to  accident  insurance  organizations. 

The  Medical  Record,  New  York 

"  This  volume  is  upon  an  important  and  only  recently  systematized  subject,  which  is  growing  in 
extent  all  the  time.     The  pictorial  part  of  the  book  is  very  satisfactory." 

SultOciY  a^rvd  Coley's 
Abdomirv^  Hernials 

Atlas  and  Epitome  of  Abdominal  Hernias.  By  Privatdgcent 
Dr.  Georg  Sultan,  of  Gottingen.  Edited,  with  additions,  by  Wil- 
liam B.  CoLEY,  M.D.,  Clinical  Lecturer  on  Surgery,  Columbia  Univer- 
sity (College  of  Physicians  and  Surgeons).  With  119  illustrations, 
36  of  them  in  colors,  and  277  pages  of  text.  Cloth,  ^^3.00  net. 

In  Sannders'  Hand-Atlas  Scries. 

During  the  last  decade  the  operative  side  of  this  subject  has  been  steadily 
growing  in  importance,  until  now  it  is  absolutely  essential  to  have  a  book  treat- 
ing of  its  surgical  aspect.  This  present  atlas  does  this  to  an  admirable  degree. 
The  illustrations  are  not  only  very  numerous,  but  they  portray  most  accurately 
the  conditions  represented. 

Robert  H.  M.  Dawb&riv.  M.D., 

Professor  of  Surgery  and  of  Surgical  Anatomy,  Neiu  York  Polvclinic. 

"  I  have  spent  several  interesting  hours  over  it  to-day,  and  shall  willingly  recommend  it  to  my 
classes  at  the  Polyclinic  College  and  elsewhere." 


S.-4  i\yi)£7x\S'   JiOOA'S  OX 


Grant's  Surgery  of 
Face,  Mouth,  and  Jaws 

A  Text=Book  of  the  Surgical  Principles  and  Surgical  Diseases  of 
the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace 
Grant,  A.M.,  M.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Hospital  College  of  Medicine  ;  Professor  of  Oral  Surgery,  Louisville 
College  of  Dentistry,  Louisville.  Octavo  volume  of  231  pages,  with 
68  illustrations.  Cloth,  ^2.50  net. 

FOR.  DENTAL  STUDENTS 

This  text-book,  designed  for  the  student  of  dentistry,  succinctly  explains  the 
principles  of  dental  surgery  applicable  to  all  operative  procedures,  also  discussing 
such  sul-gical  lesions  as  are  likely  to  require  diagnosis  and  perhaps  treatment  by 
the  dentist.  Whenever  necessary,  for  the  better  elucidation  of  the  text,  well- 
selected  illustrations  have  been  employed.  For  the  dental  student  the  work  will 
be  found  an  invaluable  text-book,  and,  indeed,  the  medical  beginner  also  will 
find  its  perusal  of  more  than  passing  benefit. 

Robson  dtivd  MoyiviKd^iv 
on  tKe  Pa^rvcreocs 

Diseases  of  the  Pancreas  and  Their  Surgical  Treatment.     By 

A.  W.  Mayo  Robson,  F.R.C.S.,  Senior  Surgeon,  Leeds  General  Infir- 
mary ;  Emeritus  Professor  of  Surgery,  Yorkshire  College,  Victoria  Uni- 
versit>%  England;  and  B.  G.  A.  Moynihan,  M.S.  (Lond.),  F.R.C.S., 
Assistant  Surgeon,  Leeds  General  Lifirmary  ;  Consulting  Surgeon  to 
the  Skipton  and  to  the  Mirfield  Memorial  Hospitals,  England.  Octavo 
of  293  pages,  illustrated.  Cloth,  1^3.00  net. 

JUST  ISSUED 

This  work,  dealing  with  the  surgical  aspect  of  pancreatic  disease,  has  been 
written  with  a  two-fold  object :  to  record  and  to  review  the  work  done  in  the  past, 
and  to  indicate,  so  far  as  possible,  the  scope  and  trend  of  future  research.  Besides 
containing  a  very  commendable  exposition  of  the  various  diseases  and  injuries  of 
the  pancreas,  the  volume  includes  an  accurate  account  of  the  anatomy,  abnor- 
malities, development,  and  structure  of  the  gland. 


SURGER  Y  AND  ANA  TOM  Y  1 3 

Ser\rv's  T\imors 

Pathology  and  Surgical  Treatment  of  Tumors.  V>y  Nicholas 
Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical  Col- 
lege, Chicago.  Handsome  octavo,  718  pages,  with  478  engravings, 
including  12  full-page  colored  plates. 

Cloth,  ^5.00  net;  Sheep  or  Half  Morocco,  ^6.00  net. 

SECOND  EDITION,  REVISED 

Books  specially  devoted  to  this  important  subject  are  few,  and  in  our  text- 
books and  systems  of  surgery  this  part  of  surgical  pathology  is  usually  condensed 
to  a  degree  incompatible  with  its  scientific  and  clinical  importance.  The  author 
spent  many  years  in  collecting  the  material  for  this  work,  and  has  taken  great 
pains  to  present  it  in  a  manner  that  should  prove  useful  as  a  text-book  for  the 
student,  a  work  of  reference  for  the  general  practitioner,  and  a  reliable,  safe  guide 
for  the  surgeon. 

Journa.1  of  the  American  Medical  Association 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illustrated,  and 
will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language  for  some  years. 
The  author  has  given  a  notable  and  lasting  contribution  to  surgery." 


Stot^ey's 

S\irgicaLl  TecKivic  for  N\irses 

Surgical  Technic  for  Nurses.  By  Emily  A.  M.  Stoney,  Super- 
intendent of  the  Training  School  for  Nurses  at  the  Carney  Hospital, 
South  Boston.      i2mo,  200  pages,  profusely  illustrated. 

Cloth,  ^1.25  net. 

The  work  is  intended  as  a  modern  text-book  on  Surgical  Nursing  in  both 
hospital  and  private  practice.  The  first  part  of  the  book  is  devoted  to  Bacteri- 
ology and  Antiseptics  ;  the  second  part  to  Surgical  Technic,  Signs  of  Death,  and 
Autopsies.  The  matter  in  the  book  is  presented  in  a  practical  form,  and  will 
prove  of  value  to  all  nurses  who  are  called  upon  to  attend  surgical  cases, 

TraLined  Nurse  and  Hospital  Review 

"  These  subjects  are  treated  most  accurately  and  up  to  date,  without  the  superfluous  reading 
which  is  so  often  employed.  .  .  .  Nurses  will  find  this  book  of  the  greatest  value  both  during 
their  hospital  course  and  in  private  practice." 


14  SAUXDERS'  BOOKS  O.Y 

Ha^ynes'  Ane^tomy 

A  Manual  of  Anatomy.  By  Irving  S.  Havnes,  M.D.,  Professor 
of  Practical  Anatonu',  Cornell  Uni\'ersity  INIecJical  College.  Octavo, 
680  pages,  illustrated  with  42  diagrams  and  134  full-page  half-tones 
from  photographs  of  the  author's  dissections.  Cloth,  ;^2.5o  net. 

In  this  book  the  great  practical  importance  of  a  thorough  knowledge  of  the 
viscera  and  of  their  relations  to  the  surface  of  the  body  has  been  recognized  by 
according  to  them  a  prominent  place  in  illustration  and  description. 

The  Medical  Record,  New  York 

"  This  book  is  ihe  work  of  a  practical  instructor — one  wlio  knows  by  experience  the  require- 
ments of  the  average  student,  and  is  able  to  meet  these  requirements  in  a  very  satisfactor)-  way.  The 
book  is  one  that  can  be  commended." 

Beck's  Fractures 

Fractures.  By  C.vrl  Beck,  M.D.,  Professor  of  Surgery,  New 
York  Post-graduate  Medical  School  and  Hospital.  With  an  Appendix 
on  the  Practical  Use  of  the  Roiitgen  Rays.  335  pages,  170  illus- 
trations. Cloth,  1^3.50  net. 

In  this  book  particular  attention  is  devoted  to  the  Rontgen  rays  in  diagnosis. 
The  work  embodies  in  a  systematic  treatise  the  important  essentials  of  this  sub- 
ject, based  on  the  extensive  experience  of  the  author  in  X-ray  work. 

The  Medical  R.ecord,  New  York 

"  The  use  of  the  rays  with  its  lechnic  is  fully  explained,  and  the  practical  points  are  brought  out 
with  a  thoroughness  that  merits  high  praise." 

AnvericaLiv  Pocket  Dictioivary 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A. 
Newman  Borland,  A.M.,  M.D.,  Assistant  Obstetrician,  Hospital  of 
the  University  of  Pennsylvania,  etc.  518  pages.  Full  leather,  limp, 
with  gold  edges,  ^i.oo  net;  with  patent  thumb  index,  $1.25  net. 

THIRD  EDITION,  REVISED 

This  is  an  absolutely  new  book.  It  is  complete,  defining  all  the  terms  of 
modern  medicine,  and  forming  an  unusually  full  vocabulary.  It  makes  a  special 
feature  of  the  newer  words  and  contains  a  wealth  of  anatomical  tables. 

Ja.mes  W.  HollaLivd.  M.D.. 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Deatt,  Jefferson  Medical 
College,   Philadelphia. 
"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.    I  can  recom- 
mend it  to  our  students  without  reserve." 


SURGER  V  AND  ANA  TOMY  i  5 

Warw^ick  and  Tunstall's  First  Aid 

First  Aid  to  the  Injured  and  Sick.  By  Y.  J.  Warwick,  B.A.,  M.B. 
Cantab.,  Associate  of  King's  College,  London  ;  and  A.  C.  Tunstall,  M.D., 
F.R.C.S.  Edin.,  Surgeon-Captain  Commanding  the  East  London  Volunteer 
Brigade  Bearer  Company.      i6mo  of  232  pages  and  nearly  200  illustrations. 

Cloth,  $1.00  net. 

"  Contains  a  great  deal  of  valuable  information  well  and  tersely  expressed.  It  will  prove 
especially  useful  to  tlie  volunteer  first  aid  and  hospital  corps  men  of  the  National  Guard." — 

Juiirnal  American  Medical  Association. 

Beck's  S\irgical  Asepsis 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.D.,  Professor  of  Sur- 
gery, New  York  Post-graduate  Medical  School  and  Hospital.  306  pages  ;  65 
text-illustrations  and  12  full-page  plates.  Cloth,  $1.25  net. 

"  The  book  is  well  written.  The  data  are  clearly  and  concisely  given.  The  facts  are  well 
arranged.  It  is  well  worth  reading  to  the  student,  the  physician  in  general  practice,  and  the 
surgeon." — Boston  Medical  and  Surgical  Journal. 

Pye's  Bandaging 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  con- 
cerning the  Immediate  Treatment  of  Cases  of  Emergency.  By  Walter 
Pye,  F.R.C.S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo, 
over  80  illustrations.  Cloth,  flexible  covers,  75  cts.  net. 

"  The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  portable, 
although  the  paper  and  type  are  good." — British  Medical  Journal. 

Senn's  Syllabus  of  Surgery 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery.  Arranged  in  con- 
formity with  "American  Text-Book  of  Surgery."  By  Nicholas  Sexx, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 

Cloth,  $1.50  net. 

"  The  author  has  evidently  spared  no  pains  in  making  his  Syllabus  thoroughly  comprehensive, 
and  has  added  new  matter  and  alluded  to  the  most  recent  authors  and  operations.  Full  refer- 
ences are  also  given  to  all  requisite  details  of  surgical  anatomy  and  pathology." — British  Medi- 
cal JournoA. 

Keen's  Operation  Blank*  second  Edition,  Revised  Form 
An  operation  Blank,  with  Lists  of  Instruments,  etc.,  Required  in  A^arious 
Operations.  Preparedby  Wm.  W.  Keen,  M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Pro- 
fessor of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical 
College,  Philadelphia.     Price  per  pad,  blanks  for  fifty  operations,  50  cts.  net. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  preparation  for 
the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics  needed." 
— Neiv  York  Medical  Record. 

Keen  on  the  Surgery  of  TypKoid 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.     By  Wm.  W. 

Keen,  M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Professor  of  the  Principles  of  Surger>' 
and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia,  etc. 
Octavo  volume  of  386  pages,  illustrated.  Cloth,  $3. 00  net. 

"  Every  surgical  incident  which  can  occur  during  or  after  typhoid  fever  is  amply  discussed  and 
fully  illustrated  by  cases.  .  .  .  The  book  will  be  useful  both  to  the  surgeon  and  physician." — 
The  Practitioner,  London. 


1 6  SL'RGER  V  AA'D  AXA  TO  MY 

Moore's  Orthopedic  Surgery 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.D.,  Professor 
of  Clinical  Surgery,  University  of  Minnesota,  College  of  Medicine  and  Surgery. 
Octavo  of  356  pages,  handsomely  illustrated.  Cloth,  $2.50  net. 

"  The  book  is  eminently  practical.  It  is  a  safe  guide  in  the  unclerstaiiding:  and  treatment  of 
orthoiJcdic  cases.    Should  be  owned  by  every  surgeon  and  practitioner." — Annals  0/ Surgery. 

Nancrede's   Anatomy   and    Dissection.     EdUron 

Essentials    of    Anatomy   and    Manual    of    Practical     Dissection.      By 

Ch.-vrles  B.  N.VNCKEDi:,  M.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 

University  of  Michigan,  Ann  Arbor.     Post-octavo  ;   500  pages,  with  full-page 

lithographic  plates  in  colors,  and  nearly  200  illustrations. 

E.xtra  Cloth  (or  Oilcloth  for  the  dissecting-room),  $2.00  net. 

"  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students  in  their 
work  in  the  dissecting-room."— yo'"««^  0/  the  American  Medical  Association. 

Nancrede's  Principles  of  Surgery 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B.  Nancrede,  M.D., 
LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  University  of  Michigan, 
Ann  Arbor.     Octavo,  398  pages,  illustrated.  Cloth,  $(2.50  net. 

"  We  can  strongly  recommend  this  book  to  all  students  and  those  who  would  see  something 
of  the  scientific  foundation  upon  which  the  art  of  surgery  is  built." — Quarterly  Medical  Journal, 
Sheffield,  England. 

Nancrede's  Essentials  of  Anatomy.  **''*Ed!??on^^'' 

Essentials  of  Anatomy,  including  the  Anatomy  of  the  Viscera.     By  Chas. 

B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  University 

of  Michigan,  Ann  Arbor.     Crown  octavo,  388  pages;   180  cuts.     With  an 

Appendix  containing  over  60  illustrations  of  the  osteology  of  the  body.     Based 

ow  Gray  s  Ana/oviy.         Cloth,  $1.00  net.     In  Saunders'  Question  Comp ends. 

"  The  questions  have  been  wisely  selected,  and  the  answers  accurately  and  concisely  given."— 
University  Medical  Magazine. 

Martin's   Essentials  of   Surgery.     ^^''XviEd"^'' 

Essentials  of  Surgery.  Containing  also  Venereal  Diseases,  Surgical  Land- 
marks, Minor  and  Operative  Surgery,  and  a  complete  description,  with  illus- 
trations, of  the  Handkerchief  and  Roller  Bandages.  By  Edward  Martin, 
A.M.,  M.D.,  Professor  of  Clinical  Surgery,  University  of  Pennsylvania,  etc. 
Crown  octavo,  338  pages,  illustrated.  With  an  Appendi.x  on  Antiseptic  Sur- 
gery, etc.  Cloth,  $1.00  net.     In  Satmders'  Question  Compejids. 

"  Written  to  assist  the  student,  it  will  be  of  undoubted  value  to  the  practitioner,  containing  as  it 
does  the  essence  of  surgical  work." — Boston  Medical  and  Surgical  Journal. 

Martin's   Essentials  of  Minor  Surgery*  Band- 
aging,   and   Venereal    Diseases.       ^^^"'gdmon"*^^'* 

Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal  Diseases.     By 

Edward  Martin,  A.M.,  M.D.,  Professor  of  Clinical  Surgery,  University  of 

Pennsylvania,  etc.   Crown  octavo,  166  pages,  with  78  illustrations. 

Cloth,  $1.00  net.     In  Saunders'  Question  Compends. 

"  The  best  condensation  of  the  subjects  of  which  it  treats  yet  placed  before  the  profession."— 
The  Medical  News,  Philadelphia. 


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